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
You are called to attend a vaginal delivery of a 40 week infant with an estimated weight of 3,000 grams (3 kg). The mother is 31 year old, G 1 P 1. Induction of labor has been started since 12 hours ago. Mom has spontaneous rupture of membrane (SROM) about 4 hours ago. Amniotic fluid showing some thick meconium staining.
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 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)? Term – 40 weeks
- Is the fluid clear? Yes
- How many babies? Singleton
- Other risk factors? Precipitous labor
- Do you need additional equipment? Yes
- Do you need more team members? Yes
Before 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
Four (4) Important Questions to Ask:
- 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.
Baby is delivered…
At birth, the important question you have to ask yourself is: Can this baby go to mom?
- Baby is TERM.
- Baby is LIMP.
- Baby is APNEIC.
- Baby has NO good muscle tone.
- Baby is LIFELESS.
DO NOT stimulate the lifeless newborn prior to intubation
Immediate Actions from birth to 30 seconds of life must be…
- Immediately intubate the lifeless newborn baby
- Do an endotracheal suctioning using the meconium aspirator
- After suctioning via ETT:
- Dry and stimulate the newborn
- Remove wet linens/ towels
- Check heart rate and listen to breath sounds
- HR = sustaining at 180’s bpm
- Crying vigorously
- Good muscle tone
At 1 minute to 5 minutes of life…
- Check HR and listen to breath sounds
- Newborn baby can go to mom
- HR = 160’s to 180’s bpm
- RR = 60’s
- Good muscle tone
- Strong, lusty cry
- 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? Yes, the baby can go to 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)
Simply Easy NRP 