The most common causes of death for infants and toddlers based on 2020 Surkesnas (National Health Survey) data regarding disease patterns that cause deaths of infants and toddlers in Indonesia are perinatal disorders and diseases of the respiratory system. Respiratory problems are one of the problems that determine morbidity and mortality rates. Premature or preterm newborns have a higher risk of experiencing respiratory problems. Babies included in the high risk group are babies with low birth weight (LBW), asphyxia in newborns, seizures, shortness of breath, flatulence in babies, jaundice in babies, and bleeding in babies.

Mechanical ventilation is an invasive measure to provide oxygen supply to babies experiencing hypoxemia. Noninvasive measures are also performed to increase the effectiveness of ventilation and perfusion. This non-invasive procedure is carried out to support invasive procedures such as installing mechanical ventilation in babies who experience respiratory problems. One of the non-invasive measures that supports oxygen therapy is positioning.

PP in neonates requiring mechanical ventilation has been found to improve oxygenation. This was stated by Balaguer, Escribano, and Figuls in a systematic review of Baby position in neonates receiving mechanical ventilation (review). A review was conducted of 11 studies of positions of neonates using mechanical ventilation that compared various positions of neonates by measuring arterial PO2, hemoglobin oxygen saturation, and episodes of desaturation. Based on this research, it was found that there was no evidence that certain body positions were relevant in improving oxygenation clinically in neonates using mechanical ventilation, but in neonates undergoing PP there was an increase in oxygenation status.

Other research related to PP was conducted by Wells, Gillies, and Fitzgerald  by examining various specific body positions on the oxygenation status of children with Acute Respiratory Distress Syndrome (ARDS). The research was conducted from 49 studies and 21 studies were selected (22 studies were published). Based on position comparisons between PP, PS, lateral, elevated and flat positions, the results showed that PP increases oxygenation more than PS, especially in premature babies.

Research on the impact of PP and PS on children experiencing respiratory failure by Kornecki, et al. showed that the oxygen index in children who underwent PP for 12 hours was better than PS, urine output increased more in PP thereby improving fluid balance compared to PS, but compliance and resistance to the static respiratory system and nitric oxide inhalation did not. important. The oxygen index in ARDS children who underwent PP for 24 hours according to Relvas, Silver, and Sagy produced a more stable decrease compared to short-term PP application (6–10 hours).

The results of research by Wells et al regarding the comparison of positions between PP, SP, lateral, elevation and flat positions show that the pronation position is more profitable than the supination position. This is seen based on the oxygen index, oxygen saturation, PaO2, arterial partial pressure of oxygen, thoraco-abdominal synchronization, and episodes of desaturation. The conclusion obtained in this study is that PP improves oxygenation more than supination, especially in premature babies. Placing the baby in PP can improve respiratory function, but requires supervision because this position is associated with sudden infant death.

The pronation position is to lay the baby face down so that the knees are bent under the stomach, while the supine position is opposite to the pronation position, the supine position is the supine position, this position is only often used in normal babies so the pronation position is more recommended for babies [1].

Several studies show that PP is a position that is easy to do and will improve oxygenation status compared to other positions in babies and neonates who use mechanical ventilation. Several studies also show that applying PP according to procedures and done correctly will not cause side effects on the baby. Based on previous research, it is also known that research on the oxygenation status of babies and neonates using mechanical ventilation before and after PP is still rarely found in Indonesia, even though PP is an action that is always carried out by pediatric nurses in the NICU.

The pronation position can have an influence in increasing and stabilizing oxygen saturation in premature babies, considering that the pronation position is given to premature babies when the premature baby's oxygen saturation is 90 percent with a pronation position intervention duration of 30 minutes to 3 hours with increasing pressure. that occurred during the intervention process was 1.02%. The research results of Alfiyah, Romadoni, Rahmania [1] found that there was a difference in the length of time babies were given the pronation position. The research results found that babies who were given the pronation position for at least 30 minutes to 3 hours would experience an increase in oxygen saturation, while babies who were given the pronation position for less than 30 minutes did not show an increase in oxygen saturation.

PP procedures and monitoring oxygenation status in infants and neonates are routine actions carried out to observe changes in oxygenation status and the clinical picture of infants with the use of mechanical ventilation. Routine activities for monitoring the baby's oxygenation status using mechanical ventilation include monitoring respiratory frequency, oxygen saturation, FiO2, and the client's clinical picture, namely changes in skin color, cyanosis, presence of apnea, and monitoring results. This monitoring will provide a clear picture of the impact of PP on the oxygenation status of babies using mechanical ventilation so that further nursing action can be recommended. Observation and monitoring of oxygenation status carried out by pediatric nurses in the NICU for babies and neonates using mechanical ventilation is an independent action by the nurse and a collaborative action if the patient's condition requires further medical action. Hospitals in Sukabumi treat babies and neonates who have various problems including respiratory problems. 

Based on preliminary studies that have been carried out, it shows that hospital nurses in Sukabumi have carried out PP on babies and neonates in the Neonatal Intensive Care Unit (NICU) and in the Special Care Nursery (SCN) 1 – 3. Most babies and neonates are treated in the NICU room. using mechanical ventilation with assist control mode, synchronized intermittent mandatory ventilation, continuous positive airway pressure and no mechanical ventilation with nasal cannula oxygen assistance. Monitoring is carried out using various equipment and monitors to monitor the patient's oxygenation and hemodynamic status. Pediatric nurses in the NICU document nursing actions and monitoring in nursing notes and observation sheets. Based on the data in nursing notes and observation sheets, it does not show any PP intervention. Based on this preliminary study, the author feels it is necessary to conduct research on the effect of pronation position intervention on premature babies who use mechanical ventilation.

Research Purposes

Analyzing the effect of the pronation position on the oxygenation status of premature babies using mechanical ventilation in the NICU Room at a Hospital in Sukabumi.

Research design is a very important thing in research. Research design is the final result of a stage of decisions taken by researchers regarding how research can be carried out. [2]. The research design used by researchers is quasi-experimental with a one-group pre-post test design approach. Data analysis in this study was a pairwise categorical bivariate comparative analysis which aimed to determine the effect of pronation position on the oxygenation status of premature babies using mechanical ventilation in the Nicu Room at Sukabumi Regional Hospital which was measured using a questionnaire before it was given. intervention (pretest) and after being given the intervention (posttest). Sampling in this research is based on non-probability sampling or non-random sampling which does not provide an equal opportunity for each element (member) of the population to be selected as a member of the sample. The sampling technique in this study used Accidental Sampling, where samples were taken from part of the existing population that researchers encountered during the research, namely 42 babies. The bivariate analysis used in this research was the paired t test. The paired t test was used to determine the differences before treatment and after treatment in the experimental group.

Based on Table 1, it shows that the average oxygen saturation before being given a pronation position in the NICU Room at Sukabumi Regional Hospital was 92.40%, with the lowest oxygen saturation being 91%, and the highest being 95%. Most of the respondents, namely 40 babies or 95.2%, had oxygen saturation <95%.

Based on Table 2, it can be seen that the average oxygen saturation after being given a pronation position in the NICU Room at Sukabumi Regional Hospital was 95.31%, with the lowest oxygen saturation being 93% and the highest being 96%. Most of the respondents, namely 36 babies or 86%, had oxygen saturation ≥95%.

Based on the results of the analysis using the paired t test, the p-value was obtained at 0.003 or smaller than the alpha value of 0.05, so that there was an influence of the pronation position on the oxygenation status of premature babies using mechanical ventilation in the NICU Room at Sukabumi Regional Hospital (Table 3).

Oxygenation Status of Premature Babies using Mechanical Ventilation before being Given a Prone Position in the NICU Room at a Hospital in Sukabumi 

The results of this study showed that the average oxygen saturation before being given a pronated position in the NICU room at a hospital in Sukabumi was 92.40%, with the lowest oxygen saturation being 91% and the highest being 95%. Most of the respondents, namely 40 babies or 95.2%, had oxygen saturation <95%.

Respondents in this study were between 2 – 17 days old with an average age of 7 days. The respondents in this study were in accordance with research by Guérin et al [3] which numbered 18 babies, however in this study the babies were more than 14 days old, and the average age of the babies was 31 days. Mendoza [4] also conducted research on 26 babies from an initial number of 33 (7 were excluded from the analysis) aged 15 – 138 days (mean=28). It is said to be the same as research conducted by researchers because it has almost the same number of respondents, average and standard deviation for age. All premature babies in this study had respiratory problems.

Respiratory problems are one of the causes of death in babies. Respiratory problems in babies are often associated with the condition Respiratory Distress Syndrome (RDS)/neonatal asphyxia, which is the biggest cause of morbidity and death in premature babies. The incidence of RDS is around 5-10% in premature babies, 50% in babies weighing 501-1500 grams. The incidence rate is related to gestational age and baby weight. The incidence of RDS has decreased since the use of exogenous surfactant as RDS therapy began, so that the incidence of RDS is less than 6% of all neonates today.There were far fewer babies treated using mechanical ventilation and using sedation/anesthesia/analgesia, namely 16.70%; compared to those who did not use the drug, namely 83.30%. This research data shows that the drugs used by these babies were Morphine (2 babies) and Midazolam (4 babies), where there was 1 baby who used these 2 drugs simultaneously. Further analysis showed that there was no relationship or influence between drug use and the oxygenation status of babies using mechanical ventilation after PP. This is possible because the number of patients using this drug is small so it is not significantly related to oxygenation status.

The average duration of use of a baby ventilator in the NICU Room at Sukabumi Regional Hospital is 5 days, with a median of 6 days, and a standard deviation of 2.775. The  shortest duration of ventilator use is 2 days and the longest is 7 days. The interval estimation results show that it is 95% believed that the average duration of ventilator use in infants is 2 – 17 days. This is possible because patients treated in the NICU experience severe respiratory problems so they use ventilators for a long period of time and the weaning process (including decreasing FiO2) is carried out gradually and over a long period of time.

Table 1: Oxygenation Status of Premature Babies using Mechanical Ventilation before being Given a Prone Position in the NICU Room at a Hospital in Sukabumi

Table 2: Oxygenation Status of Premature Babies using Mechanical Ventilation before after being Given a Pronation Position in the NICU Room at a Hospital in Sukabumi

Table 3: The Effect of Pronation Position on the Oxygenation Status of Premature Babies Using Mechanical Ventilation in the NICU Room at a Hospital in Sukabumi

Oxygenation status of Premature Babies using Mechanical Ventilation after being Given a Pronation Position in the NICU Room at a Hospital in Sukabumi

Based on the research results, the average oxygen saturation after being given a pronation position in the NICU room at a hospital in Sukabumi was 95.31%, with the lowest oxygen saturation being 93% and the highest being 96%. Most of the respondents, namely 36 babies or 86%, had oxygen saturation ≥95%.

The average SpO2 value in babies using mechanical ventilation in the NICU at Sukabumi Hospital before PP was carried out was 92.40%. After PP was maintained for 30 minutes, the average SpO2 value in babies using mechanical ventilation increased to 95.31 ± 2.31, then after PP was maintained for 1 hour, the average SpO2 value in babies increased to 95.20. PP for 2 hours has an average SpO2 value of 96.22. Based on the research data above, it is known that during PP before and after PP with measurements at 30 minutes, 1 hour and 2 hours there was a significant increase in SpO2 (P value = 0.0016, α = 0.05). Further analysis showed that there were differences in SpO2 in the four measurements before PP and after PP when measured after 2 hours. This shows that the longest PP shows a significant difference in the baby's SpO2 status.

According to Hockenberry and Wilson [5], a respiratory problem that interferes with a baby's oxygenation is Apnea of Infancy (AOI). This condition generally occurs at a gestational age of more than 37 weeks. The clinical symptoms that appear in infants are described as a combination of (1) apnea (no breathing for 20 seconds or more); (2) cyanotic or pale skin color; (3) changes in muscle tone; and (4) strangulation or airway obstruction. AOI can be caused by other health problems such as sepsis, seizures, upper respiratory tract disorders, gastrosophageal reflux, hypoglycemia or metabolic problems, and impaired respiratory control. Life-threatening conditions in babies often occur in babies who have lung problems such as lack of surfactant fluid and slow ventilator response to hypercapnia and hypoxia. A diagnosis of AOI is given if the cause of the baby's life-threatening condition cannot be identified.

A higher oxygen saturation value in PP than in PS was also found by Apriliawati [4] who compared PP and PS positions for 1 hour in term neonates. It is known that the average oxygen saturation is 99.1 ± 1.2 in PP and 98.8 ± 1.6 in PS, but the results of further analysis did not show a significant difference. This is in accordance with the results obtained in this study where an increase in oxygen saturation also occurred when measuring PP for 1 hour but was not a group that experienced significant differences in oxygen saturation values before PP. The increase in SpO2 in patients undergoing PP is related to respiratory physiology. Placement with PP will affect oxygen perfusion. This is because lung perfusion is greatly influenced by body posture, and perfusion in PP is greater than in PS (PS 1.62 ± 0.69 ml/min.cm3 compared to PP 2.26 ± 0.92 ml/min.cm3, p-value < 0.05). 

Guérin et al [3] also stated that the impact of PP oxygenation on the distribution of alveolar inflation would be more homogeneous. The increase in anterior lung density is smaller than the decrease in posterior lung density, this shows that in PS the pressure in the posterior part is greater. The size of the lung weight will affect the redistribution of intrapulmonary air. This redistribution of intrapulmonary air is related to hydrostatic pressure, in PP it is likely that the dependent lung area, namely the ventral area, is less likely to collapse.

The Effect of the Pronation Position on the Oxygenation Status of Premature Babies using Mechanical Ventilation in the NICU Room at a Hospital in Sukabumi

In the analysis of the strength of influence, a correlation value of 0.003 or smaller than 0.05 was obtained so that there was an influence of the pronation position on the oxygenation status of premature babies using mechanical ventilation in the NICU Room at Sukabumi Regional Hospital.

Giving the pronation position had an impact on oxygen saturation which initially averaged 92.87 which gradually increased to 95.46 in the first hour and 96.25 in the first 2 hours with increasingly smaller deviations. Normal oxygen saturation ranges from 90 – 98%. Monitoring oxygen saturation is necessary to prevent retinopathy in premature babies. Oxygen should be given if oxygen saturation is below 90%. Based on detailed research data, there are babies who have saturation below 90%. The results of observations of babies weighing 700 grams showed that the oxygen saturation condition before pronation was 86% to 96% and 98%, meaning that the saturation condition improved with the pronation position. The results of the study showed that the types of respiratory problems found in asphyxia sufferers included meconium aspiration syndrome (6 sufferers), pulmonary hypertension (3 sufferers), pulmonary hemorrhage (4 sufferers), and the remainder suffered from temporary respiratory problems in newborn babies.

The difference in the baby's oxygen saturation before and after giving the pronation position with an SD of 2.72 with a significance of 0.000. This means that there is an effect of giving the pronation position for 1 hour on the state of oxygen saturation. Apart from that, there was also a difference in the baby's oxygen saturation before and after giving the pronation position in the first 2 with an SD of 3.71 with a significance level of 0.000. The statistical test significance result is 0.000, meaning that there is a significant effect of providing a pronation position for 1 hour and 2 hours on the state of oxygen saturation. The results of univariate analysis showed a mean saturation of 92.87-95.46 (1 hour) - 96.25 (2 hours).

Giving babies in a pronated position in this study had a gradual impact, namely changes in oxygen saturation that got better every hour. The reason is, the pronation position provides comfort so that the baby is calmer, which has an impact on smooth blood circulation in the body. In line with research conducted by Suek [6], there was a significant difference between oxygen saturation before and after intervention (pronation position) with a value of p0.004 (p<0.005, α: 0.05). This means that the pronation position is effective in increasing oxygen saturation. This is also in line with the research results of Apriliawati [4] which stated that there was a significant difference in oxygen saturation with a p-Value of 0.032.

The research results of Alfiyah, Romadoni, Rahmania [1] stated that there was a significant difference in oxygen saturation with pulse oximetry in babies who used mechanical ventilation before - after the pronation position with Pv 0.004. This is different from the results of research by Kusumaningrum  which showed that the SpO2 value of babies in the pronation position did not affect oxygenation, but did affect the increase in pulse rate and the pulse rate tended to be stable.

According to researchers' assumptions based on research results, the pronation position can have an influence on increasing and stabilizing oxygen saturation in premature babies. that occurred during the intervention process was 1.02%-2.46%. There is a difference in the length of time babies are given the pronation position, babies who are given the pronation position for at least 30 minutes to 2 hours will experience an increase in oxygen saturation, while observations of babies who are given the pronation position. less than 30 minutes does not show an increase in oxygen saturation.

Most of the respondents, namely 40 babies or 95.2%, had oxygen saturation <95% before being given the pronation position in the NICU Room at Sukabumi Regional Hospital. Most of the respondents, namely 36 babies or 86%, had oxygen saturation ≥95% after being given a pronation position in the NICU Room at Sukabumi Regional Hospital. There is an influence of the pronation position on the oxygenation status of premature babies using mechanical ventilation in the NICU Room at Sukabumi Regional Hospital. The p-value of the paired t test was obtained at 0.003 or smaller than the alpha value of 0.05.

Giving babies in a pronated position in this study had a gradual impact, namely changes in oxygen saturation that got better every hour. The reason is, the pronation position provides comfort so that the baby is calmer, which has an impact on smooth blood circulation in the body. It is recommended that the results of this study can be used as evaluation material in determining policies regarding the effectiveness of the pronation position on the oxygenation status of premature babies using mechanical ventilation.

1. Alfiyah, K.U. et al. “Pengaruh posisi pronasi terhadap saturasi oksigen pada bayi prematur: literature review.” Indonesian Journal for Health Sciences vol. 6, no. 1, 2022, pp. 8–16.

2. Nursalam. “Metodologi penelitian ilmu keperawatan: pendekatan praktis.” 5th ed., Salemba Medika, 2020.

3. Guérin, C. et al. “Prone position in ARDS patients: why, when, how and for whom.” Intensive Care Medicine vol. 46, no. 12, 2020, pp. 2385–2396.

4. Apriliawati, A. “The effect of prone position to oxygen saturation level and respiratory rate among infants who are on mechanical ventilation in NICU Koja Hospital.” IMC Proceedings vol. 1, no. 1, 2017.

5. Hockenberry, M.J. and Wilson, D. “Wong’s essentials of pediatric nursing.” 8th ed., Elsevier, 2014.

6. Suekdiana, O. “Pengaruh posisi pronasi terhadap status hemodinamik anak yang menggunakan ventilasi mekanik di ruang PICU RSAB Harapan Kita Jakarta.” Universitas Indonesia, 2012.