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 full term vaginal delivery of a 34 week infant in progress. with an estimated weight of 2,000 grams (2 kg). Mother is 27 year old, G 2 P 1. She has good prenatal care and no prior history of health issues. Prenatal care shows no complications.
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, and immediately take a quick look at the 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 ask the following:
- Is the baby term? What is the gestational age (GA)? preterm – 34 weeks
- Is the fluid clear? Yes
- How many babies? Only one baby
- Other risk factors? No risk factors, mom has good PNC
- Do you need additional equipment? Yes
- Do you need more team members? Yes
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 the OB provider:
- Is the baby term? The baby is preterm.
- Is the fluid clear? The fluid is clear.
- How many babies are there? One baby
- Any other risk factors? It’s a vaginal delivery and has good prenatal care.
Baby has been delivered…
The most important question to ask yourself: Can this baby go to mom? Baby looks, OK. No problem at this time.
- Baby is PRETERM.
- Baby is with good spontaneous breathing and crying vigorously.
- Baby has good muscle tone.
- Not in distress with good respiratory effort.
From birth to 30 seconds of life…
- Baby is placed on radiant warmer
- Dry and stimulate the newborn for 30 seconds
- CHECK heart rate (HR) and LISTEN to breath sounds
At 30 seconds…
- Check HR and listen to breath sounds
- HR = 120 – 140 bpm
- RR = 40 – 60 per minute
- Newborn has good muscle tone
- Newborn has strong, active movement
However,
- Breath sounds are unequal and there is a poor chest rise on the right side of the chest
Immediate action:
- Provide EFFECTIVE 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
Newborn baby begins to deteriorate…
- Newborn showing signs and symptoms of respiratory distress syndrome (RDS)
- Nasal flaring
- Retractions
- Grunting
- HR = 150’s bpm
- RR = 60’s per minute
- SpO2 readings dropping below the targeted range
- FiO2 requirement adjusted accordingly, but newborn continue to deteriorate
- Condition worsens
Immediate action:
- Keep newborn from deteriorating, monitor
- Perform needle aspiration or needle decompression
In order to continue with effective PPV, needle decompression needs to be done ASAP
- If PPV continues without needle aspiration or decompression; newborn infant will go into full respiratory arrest within 3 minutes of life.
At 3 minutes of life…
If needle decompression is SUCCESSFUL, the newborn infant will survive
- Check HR and listen to breath sounds
- HR = 100’s bpm and rising
- occasional spontaneous breaths
- SpO2 @ 80% and increasing
- 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
Note: NRP Guidelines for Effective Resuscitation
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 