NRP Case Study 1 – Baby is OK

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.

1. Warmer
2. Clear the airway if necessary
3. Dry the newborn
4. Auscultate
5. Oxygenate
6. Ventilate
7. Intubate
8. 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 an emergency cesarean birth due to prolonged fetal bradycardia. It is a term pregnancy, mom is in labor for about 8 hrs. Variability started to decrease with some decelerations and the HR went down due to prolonged deceleration. OB team able to back up HR to 70 bpm. Delivery cesarean section (C/S) is imminent.

Given the above scenario, you ask yourself:

• How would you prepare for the resuscitation of this baby?

Before the birth, you should ask the OB provider the following questions:

• Is the baby term? example answer: Baby is term.
• What is the gestational age (GA)? example answer:  Gestational age is 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

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.

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 term pregnancy, 40 weeks GA, amniotic fluid is clear, singleton; for emergency cesarean birth due to prolonged fetal bradycardia. Mom is in labor for about 8 hrs. Variability started to decrease with some decelerations and the HR went down due to prolonged deceleration. OB team able to back up HR to 70 bpm. Delivery C/S is imminent. You may need additional team members to come in and help resuscitate the baby. Also, additional equipment and supplies may be needed.

Once again, prior to delivery, you have to keep in mind EIGHT (8) THINGS THAT YOU NEED THE MOST.

1. Warmer
2. Clear the airway if necessary
3. Dry the newborn
4. Auscultate
5. Oxygenate
6. Ventilate
7. Intubate
8. 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? 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.

Baby is out…

• WARM – Dry and stimulate the newborn for 30 seconds
• CHECK heart rate (HR) and LISTEN to breath sounds

At birth to 5 minutes of life…

Newborn baby is crying vigorously, NOT limp, NOT apneic, HR = is > 100 bpm

• NO NEED to provide positive pressure ventilation (PPV) for 30 seconds
• NO NEED to call for additional help
• NO NEED to apply pulse oximeter to right palm of hand or right wrist
• NO NEED to perform MR. SOPA
• NO NEED to administer free flow oxygen

Important Question to ask yourself: Can this baby go to mom?

• Baby is TERM. 
• Baby is breathing and crying. 
• Baby has good muscle tone.

YES, the baby can go to his mom. 

Following 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.

—————————————————————————

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)