Orientation to the world of newborn

Topics coveredThe NICU

◦where to go◦what to do

Delivery room set up Review of neonatal resuscitation

Learning ObjectivesUnderstand

◦various mode of thermoregulation◦importance of communication◦steps in resuscitation of newborn

The NICU2nd floor at Lakeside HospitalPlease be at NICU by 7.30am3 minute scrub prior to entering

NICUWear gloves for all patient

contact Wash hands between patientsPlease use the baby’s individual

stethoscope (found at baby’s bedside)

Scrub before entering NICU

Waterless Hand Wash

The NICUAttend at least 1 delivery with

NNP or residentsIf parents ask questions, please

refer them to medical teamMute cell phone & talk softly

around babiesPlease wear scrubs while in the

NICU

The NICUPeople you will see in the NICU

◦ Charge nurse◦ Bedside nurse (usually have 2-3

babies per nurse)◦ Respiratory therapists (usually 2 in

NICU)◦ Neonatal nurse practitioners

Nancy Wood Kathy Smith Shelly Holcomb Julie Evans Angie Noya

The NICUAssigned patients by the

residents◦ Review history and physical with

residents◦ Pre-round with residents◦ Review laboratory and radiology

results with residents◦ Talk to RNs about patient and prior

to examining patient

Isolation Room – Gown & Glove

Isolette

The NICUPresent patients during rounds

(usually starts around 8.30-9.00am)◦ Brief history and current problems◦ Issues overnight◦ Vital signs, current weight & change

in weight◦ Brief review of physical examination

The NICUPresent patients during rounds

◦ Intake (Type of feeds, TPN, amount, nipple/gavage)

◦ Total intake (mL/kg/day) and output (mL/kg/hr)

◦ Laboratory, radiology, consult results

◦ List of medications◦ Assessment and plan for the day

The NICURounds usually end by 11.30amNoon conference (for residents)Please remind attending and

residents on days you will not be present in the afternoon

In the afternoon or prior to leaving for the day◦ Check up on your patient◦ Review assessment and plan with

residents

The Delivery RoomNeed to wear

◦ Head cover◦ Mask◦ Shoe cover◦ You may be asked to scrub and wear

scrub gown to receive babyStand around radiant warmerSpeak softly Be aware of sterile fields!

Hats, masks, shoe covers before entering OR

Scrub area in OR

Neonatal ResuscitationMost newborn transition to

extrauterine life without complications

~10% require some intervention10-20% from above require

aggressive intervention

Preparation prior to deliveryAdequate personnel

◦Open communication with OB team◦Should have minimum of 3 person

trained in NRP for high risk deliveries◦Good communication within team◦Good coordination of function for

each team member

Preparation prior to deliveryObtain information from OB

nurses◦Gestational age of baby◦Why are we delivering? ◦Is meconium present (if membranes

ruptured)◦Any pertinent maternal history?

Fever Pertinent labs Complications during pregnancy/labor

Pass above information to rest of team!

Preparation prior to deliveryEquipments

◦Radiant warmer ◦Warm blankets (lots of it!)◦Stethoscope◦Plastic wrap for babies <1000g◦Bag-mask ventilation ◦Oxygen blender◦Laryngoscope ◦Endotracheal tubes◦Suction

Preparation prior to deliveryRadiant warmer

◦Switch on when enter delivery room◦Provides radiant heat ◦Make sure sides are up to prevent

convective heat lossWarm dry blankets

◦Provides conductive heat◦Prevents evaporative heat loss

Radiant warmer in DR

Preparation prior to deliveryCheck equipments

◦Put on gloves!◦Resuscitation bag, air flow & oxygen◦Suction device (bulb and wall

suction)◦Meconium aspirator (if meconium

present)◦Laryngoscope and endotracheal tube

Preparation prior to deliveryEnsure have adequate personnel Assign roles to team members

◦Be specific (who, what, when)◦Be aware of what and how team

members are performingVocalize findings/difficulties to

team membersDo not be afraid to CALL FOR

HELP

Initial ResuscitationProvide warmth

◦Turn on radiant warmer◦Place baby on warm dry blanket

Dry and Stimulate◦Dry baby with warm dry blanket◦Remove wet linen from baby

Initial ResuscitationAirway

◦Clear airway with bulb syringe Mouth 1st, nose 2nd

◦Position baby to open airway

Initial ResuscitationBreathing

◦Primary apnea Can be reversed by stimulation Rub backs and flick heels Do NOT turn baby upside down!

◦ Secondary apnea Require bag and mask ventilation May require endotracheal intubation

Initial ResuscitationPick the right size of mask

◦Fit from bridge of nose to chin◦Do not cover eyes

Wood FE et al; Arch Dis Child – Fetal and Neonatal Ed 2008;93:F230-4

Flow-inflating bag

Initial resuscitationBreathing

◦Term infant may require peak PIP 20-30 cmH20 initial inflation pressure

◦Provide 30-60 breaths a minute

Initial resuscitationCirculation

◦Assess color, tone and heart rate◦Palpate brachial and umbilicus for

pulse◦Tap out heart rate◦Chest compression if needed

2 different techniques

Assessing Heart Rate

Palpation for brachial pulse

Palpation for umbilical pulse and Auscultation by stethoscope

Chest compression techniques

2 finger technique

2 hand technique – thumbs side-by-sideover midsternum

Transport Isolette

Apgar ScoresDeveloped by Virginia Apgar in

1953To assess effectiveness of

resuscitative effortsAssess heart rate, respiration,

color, tone and grimace

Apgar Scores (How Ready Is This Child?)

0 Points 1 Point 2 Points

Heart rate Absent <100bpm >100bpm

Respiration Apnea Gasping, irregular

Strong cry

Irritability Absent Facial grimace Sneeze, cough, pulls away

Tone Absent Arms & legs extended

Active movements

Color Blue-gray, pale all over

Pink body, blue extremities

Pink all over

Assessment of tone

Normal tone in term newborn

Assessment of color

Acrocyanosis

Cyanotic newborn

Algorithm of resuscitationBirth

Term?Amniotic fluid clear?Breathing?Good tone?

WarmPositionClear airwayDry, stimulate, reposition

Yes Routine care- Warm- Dry- Clear Airway- Assess colorNo

Algorithm of resuscitation

Evaluate breathing, HR, Color & tone

HR <100 or apnea 30s

Positive pressure ventilation

HR <60 30s

Ensure effective inflation Start chest compression

HR <60 30s

Medications

www.exutero.wordpress.comVisit this link while in NICU

rotationFor Students: review articles Complete test (may work in

group)For Interns: complete 4

consecutive (weekly) resident readiness tests◦Email completed tests to Priscilla

Busch pbusch@tulane.edu Completion of assigned test(s) is

mandatory. Failure to Complete a test will result in

failure of the rotation (for students or interns).

THANK YOU!

QUESTIONS?