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 vaginal delivery of a 40 week infant with an estimated weight of 4,000 grams (4 kg). The mother is a G 2 P 2, 45 year old, with a history of Diabetes Mellitus and viral illness during pregnancy. Mother has been in labor for 8 hours and is crowning. Her delivery is imminent.
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 L&D.
Earlier on at the beginning of your shift, you have performed the EQUIPMENT CHECKS. You are prepared to attend to this delivery as you have done all your initial 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.
Prior to the newborn’s birth, you have asked the following questions:
- 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
EIGHT (8) THINGS THAT YOU NEED THE MOST.
- Warmer
- Clear the airway if necessary
- Dry the newborn
- Auscultate
- Oxygenate
- Ventilate
- Intubate
- Medicate
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? Singleton
- Any other risk factors? It’s a vaginal delivery and mom is just about to deliver. Baby’s head is crowning already.
Finally, the baby is out…
- Important Question to ask yourself: Can this baby go to mom?
No, the baby cannot go to the mom immediately due to obvious central cyanosis
- Baby is TERM.
- Baby is active but not vigorous
- Baby is breathing with weak cry.
- Baby has good muscle tone.
- Baby has very obvious central cyanosis
Initial Steps, birth…
- Warm the newborn – place on radiant warmer
- Dry and stimulate the newborn for 30 seconds
- Remove wet linens
At birth to 30 seconds of life…
- Check heart rate (HR) and listen to breath sounds
- HR = 150 bpm
- RR = 60 per minute
- Not in respiratory distress
- Not apneic
- No nasal flaring
- No retractions
- No grunting
- Not limp, not lethargic
- Huge murmur heard on auscultation
- Pulse oximeter placed on newborn’s right wrist
- NO NEED to provide positive pressure ventilation (PPV)
Call for additional HELP, UVC placement immediate action; chest X-ray a must!
At 1 minute of life…
- Check HR and listen to breath sounds…
- Give 100% oxygen
- If SpO2 drops to less than acceptable SpO2 reading range (e.g. 50%)
- At SpO2 50%, baby is deteriorating
- Start PPV to see if condition will improve; if no change in condition, problem may be cardiac
- No signs of respiratory distress (e.g. RR = 70-80 per minute)
- HR = 160 bpm to 180 bpm, remains on the high side
At 1 minute and 30 seconds of life…
- Check HR and listen to breath sounds
- Start with immediate ventilation: condition NO change; just same
- HR = 160’s to 180’s
- RR = 70’s to 80’s
- Pale
- starting to show muscle weakness, limp
- If ventilation has not started: condition worsens; continue to deteriorate
- HR = 200’s
- RR = 80’s to 90’s
- SpO2 at 50% and condition remains deteriorating
At 2 minutes of life…
- Check HR and listen to breath sounds
- Order STAT chest X-ray
- Continue ventilation to keep:
- HR = 180’s
- RR = 80’s
- Pale, limp
- If ventilation stops: condition worsens
- HR = 210’s
- RR = 90’s
- Spo2 = 50% – 40% and continues to drop
At 2 minutes and 30 seconds of life…
- Order for cardiac medication:
- Prostin (Prostaglandin), if started SpO2 increases to 60% to 70%
- Check HR and listen to breath sounds
- If cardiac medication not ordered: Prostin not started
- Newborn’s condition continue to deteriorate
- vital signs (VS) very unstable; worsens condition
- SpO2 dropping rapidly
- Newborn will die immediately
DEATH is imminent
Continue with ventilation and continuous Prostin infusion until newborn baby transported to NICU
- Place an (oro-gastric tube) OGT F#8 or F#10
Transfer to NICU for further evaluation and management of condition, will continue to monitor condition…
- 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
NOTE: Important NRP Guidelines to Remember when Resuscitating a Newborn
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 