Description:
Today, you are assigned as the ‘admit nurse.’ While in the NICU and waiting for any delivery in L&D, your main duty is to prepare and check the admission bed, check the procedure cart, resuscitation equipment, and Kangaroo Board supplies that you may need to use during the admission process. Set-up an admission bed with all the necessary equipment and supplies within reach.
Eight (8) Things to Remember when setting up an admission bed in case you need to resuscitate a newborn. Always keep in mind to have all of these available on hand in case you encounter an emergency situation.
Warmer
Clear the airway if necessary
Dry the newborn
Auscultate
Oxygenate
Ventilate
Intubate
Medicate
In other facilities it is either the job of the charge RN or the admitting RN to run to delivery and receive the newborn baby for admission to NICU, if the baby’s condition require to do so. However, in this scenario, let say the charge RN went to break, so it is the sole responsibility of the ‘1st admit nurse’ to catch the newborn in L&D.
You are called to attend a cesarean section delivery of a 40 week infant with an estimated weight of 4500 grams (4.5 kg). The mother is a G 1 P 1, 40 year old, and her last delivery was by emergency C-section. Mother has been in labor for 18 hours and within the last 20 minutes fetal heart rate tracings have become concerning due to intermittent late decelerations.
Given the above scenario, you ask yourself:
How would you prepare for the resuscitation of this baby?
As soon as you received the call from the L&D nurse, you immediately went to Labor and Delivery OR to start the following checks: EQUIPMENT CHECKLIST
Prepare all the needed equipment and supplies for this delivery.
Obtain relevant perinatal history.
Performs equipment check.
Assembles resuscitation team.
Prepares for intubation.
Before the birth, you should ask:
Is the baby term? What is the gestational age (GA)? example answer: Term – 40 weeks
Is the fluid clear? example answer: Yes
How many babies? example answer: One
Other risk factors? example answer: Precipitous labor
Do you need additional equipment? example answer: Yes
Do you need more team members? example answer: Yes
Basically, it is either the L&D nurse or the OB in-charge will update or give you more information about the mother’s history.
In this case: The L&D nurse in the OR gave you additional perinatal history as follows:
This is a C/S delivery for a 40 week infant with an estimated weight of 4500 grams (4.5 kg). The mother is a G 1 P 1, 40 year old, and her last delivery was by emergency C-section. Mother has been in labor for 18 hours and within the last 20 minutes fetal heart rate tracings have become concerning due to intermittent late decelerations.Amniotic fluid was clear. The infant required forcep assist at delivery and is placed on the warmer limp, cyanotic, and apneic.
Once again, prior to delivery, you have to keep in mind EIGHT (8) THINGS THAT YOU NEED THE MOST.
Warmer
Clear the airway if necessary
Dry the newborn
Auscultate
Oxygenate
Ventilate
Intubate
Medicate
At 21:00 – The baby is out. As soon as the baby is out…
Four (4) Important Questions to Ask the OB provider:
Is the baby term?
The baby is term.
Is the fluid clear? The fluid is clear.
How many babies are there? One baby, that is good.
Any other risk factors? It’s a vaginal delivery and mom is having precipitous labor, mom is giving birth fast. The NICU nurse’s sole responsibility is the INFANT.
Important Question to ask yourself: Can this baby go to mom?
Baby is TERM.
Baby is breathing and crying.
Baby has good muscle tone.
Succeeding Actions:
Cord has been clamped and cut.
Baby goes to mom.
The nurse’s role is to dry the baby off.
Making sure the baby is breathing and getting better moment to moment.
Baby can get a lot of negative reactions on their first few minutes; they can cough, choke, and be tachypneic, they can have a big murmur, they can grunt.
But over all, he needs to get better, moment to moment.
Baby is out…
WARM – Dry and stimulate the newborn for 30 seconds
CHECK heart rate (HR) and LISTEN to breath sounds
At 30 seconds…HR = 20 bpm, LIMP, APNEIC
Provide positive pressure ventilation (PPV) for 30 seconds
Call for additional HELP
Apply pulse oximeter to right palm of hand or right wrist
At 1 minute of life…
Check HR and listen to breath sounds…
HR = 65 bpm
LIMP
APNEIC
30 more seconds, perform MR. SOPA
At 1 minute and 30 seconds…
Check HR and listen to breath sounds
HR = 70 bpm
newborn still LIMP
SpO2 @ 50%
Continue with PPV for another 30 seconds – at 2 minutes of life…
Check HR and listen to breath sounds
HR = 76 bpm
NO spontaneous respirations
newborn remains LIMP
SpO2 @ 60%
Continue with PPV for 30 seconds – at 2 minutes and 30 seconds…
Check HR and listen to breath sounds
HR = 80 bpm
newborn starting to pink up
newborn has increase in muscle tone
newborn showing occasional weak gasps
SpO2 @ 75%
Continue with PPV for another 30 seconds – at 3 minutes of life…
Check HR and listen to breath sounds
HR = 100 bpm
occasional spontaneous breaths
SpO2 @ 80%
newborn showing increase in muscle tone
Turn oxygen requirement (FiO2) down according to current SpO2 readings
Place an (oro-gastric tube) OGT F#8 or F#10
Decrease ventilation rate
Watch for improving respiratory effort
Continue to stimulate newborn to breathe
At 3 minutes and 30 seconds
Check HR and listen to breath sounds
HR = 125 bpm
newborn pinking up gradually
muscle increasing in tone
newborn becoming more active
respirations regular in rate and rhythm, but weak
SpO2 @ 85%
Continue with PPV for 30 seconds – at 4 minutes of life…
Check HR and listen to breath sounds
HR = 180 bpm
newborn awake, active, and alert
lusty and vigorous cry
SpO2 @ 90%
Discontinue PPV and administer free flow oxygen
Discontinue free flow oxygen when SpO2 reading remains above 85%
Do not forget to remove OGT
Prepare the newborn for mom to hold
Explain to mom that newborn will go to nursery for post-resuscitation care;
and for further management and care if any problems may rise later
Corrective Steps
M – Mask adjustment
R – Reposition airway
S – Suction mouth and nose
O – Open mouth
P – Pressure increase
A – Airway alternative
Targeted Pre-ductal SpO2 After Birth
1 min 60% – 65%
2 min 65% – 70%
3 min 70% – 75%
4 min 75% – 80%
5 min 80% – 85%
10 min 85% – 95%
Endotracheal Intubation
Gestational Age (weeks) Weight ET Tube Size* Depth of insertion **
< 28 weeks < 1 kg 2.5 6 – 7
28 – 34 1 – 2 kg 3.0 7 – 8
34 – 38 2 – 3 kg 3.5 8 – 9
38 > 3 kg 3.5 – 4.0 9 – 10
Depth of Insertion ( cm from upper lip) = 6 cm + weight (in kilograms [kg])
(Internal Diamete [ID2] mm)
Medications:
Epinephrine via UVC
Precaution:
Give rapidly
Repeat every 3 to 5 minutes if HR < 60 bpm with chest compressions
Higher IV doses not recommended
Route: Intravenous (IV) —> Umbilical Vein Catheter
UVC is the preferred route
Dosage: 0.1 to 0.3 ml/kg
Concentration: 1 : 10,000
WEIGHT (kg) Total IV volume (ml)
1 0.1 to 0.3 ml
2 0.2 to 0.6 ml
3 0.3 to 0.9 ml
4 0.4 to 1.2 ml
Epinephrine via ETT *
Concentration: 1 : 10,000
Dosage: 0.5 to 1 ml/kg
Route: ETT
WEIGHT (kg) Total IV volume (ml)
1 0.5 to 1 ml
2 1 to 2 ml
3 1.5 to 3 ml
4 2 to 4 ml
Note : Endotracheal dose may not result in effective plasma concentration of drug, so vascular access should be established as soon as possible. Drugs given endotracheally require higher dosing than when given IV.
Volume Expanders
Isotonic or crystalloid – Normal Saline (NS) or blood
Dosage: 10 ml/kg
Route: Intravenous (IV) or UVC
not to be given via ETT
Precautions:
Give over 5 to 10 minutes
Reassess after each bolus
Indication: Indicated for shock
WEIGHT (kg) Total IV volume (ml)
1 10 ml
2 20 ml
3 30 ml
4 40 ml
Final thoughts on your skills return demonstration:
As you work, say your thoughts and actions aloud so I will know what you are doing.
Sources: All rights reserved.
American Academy of Pediatrics 2011
American Heart Association (AHA)
Simply Easy NRP 