NRP Case Study 7


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 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.

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

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