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 spontaneous vaginal delivery of a 29 week infant with an estimated weight of 1,200 grams (1.2 kg). The mother is a G 0 P 0, 18 year old with poor prenatal care and a history of poor nutrition during pregnancy. Mom’s bag of water broke on her way to the hospital emergency room. She is in active labor and her delivery is imminent. A baby boy was delivered with Pierre Robin’s Syndrome and bilateral cleft palate.
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 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? No, not term
- What is the gestational age (GA)? example answer: preterm – 29 weeks
- Is the fluid clear? No, bloody
- How many babies? One baby only
- Other risk factors? Bag of water broke prematurely
- Do you need additional equipment? Yes, preterm delivery
- Do you need more team members? Yes, preterm delivery
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.
Prior to delivery, keep in mind the 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 provider:
- Is the baby term? The baby is NOT term.
- Is the fluid clear? The fluid is NOT clear. It’s bloody.
- How many babies are there? One baby only
- Any other risk factors? It’s a vaginal delivery and mom is having imminent labor, mom is giving birth fast.
Remember: The NICU nurse’s sole responsibility is the newborn baby. The mom is the responsibility of the L&D nurse. NICU RN, must look after the baby’s immediate needs.
Baby is out…
The most important question to ask yourself when the baby is born: Can this baby go to mom? NO, the baby cannot go to the mom due to his condition.
- The baby is PRETERM.
- The baby is born with vigorous and lusty cry; BUT condition immediately worsens
- The baby show signs and symptoms of respiratory distress
- The baby is NOT breathing and crying, lifeless
- The baby has poor muscle tone, limp
Immediate initial actions after birth to 30 seconds of life…
- Placed on radiant warmer
- Dry and stimulate the newborn for 30 seconds
- Remove wet linens
At first 30 seconds…
- Check heart rate and listen to breath sounds
- Provide positive pressure ventilation (PPV) for 30 seconds
- While performing PPV, you listen to breath sounds again
- NO breath sounds heard on both lung fields
Expected Action for Pierre Robins Syndrome:
- Immediate intubation with Laryngeal Mask Airway (LMA)
- Continue with PPV via LMA
- Re-assess effectiveness of PPV and re-check for presence of breath sounds
If LMA intubation is effective, good bilateral breath sounds must be heard on both lung fields
At 1 minute of life…
- Continue with PPV
- Check HR and listen to breath sounds
- HR = 50’s bpm and increasing
At 1 minute and 30 seconds of life…
- Continue with PPV
- Check HR and listen to breath sounds
- HR = 70’s bpm and increasing
- newborn becoming active
- SpO2 @ 60% and increasing; FiO2 adjusted accordingly as needed
At 2 minutes of life…
- Continue with PPV
- Check HR and listen to breath sounds
- HR = 90’s bpm and improving
- SpO2 @ 70% and increasing; FiO2 adjusted accordingly as needed
At 3 minutes of life…
- Check HR and listen to breath sounds
- HR = 100’s bpm
- occasional spontaneous breaths
- SpO2 @ 80%; FiO2 adjusted accordingly as needed
- Place an (oro-gastric tube) OGT F#8 or F#10
At 4 minutes of life…
- Check HR and listen to breath sounds
- HR = 160’s bpm
- SpO2 @ 95% and oxygen requirement adjusted accordingly
- Explain to mom that newborn will go to NICU for further evaluation and management; and care if any problems may rise later
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Note: NRP Guidelines to follow when performing resuscitation measures to newborns and infants
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 