Case study: Here are 5 key steps you must take
Case study: Here are 5 key steps you must take
When an expectant mother came to the ED complaining of cramping for several days, she told nurses that she had no prenatal care and was "about seven months along," says Robin Clifton-Koeppel, MS, RNC, CPNP, a neonatal clinical nurse specialist and pediatric nurse practitioner at University of California — Irvine Medical Center in Orange. "It became evident that her cramping’ sensations were actually contractions, and the infant was delivered on the ED gurney," she recalls.
Immediately, the nurse placed the preterm newborn on a radiant warmer and began to dry the infant, suction the mouth and nose with a bulb syringe, and stimulate the infant. She also assessed the newborn for activity, breathing, color, and heart rate. "Unfortunately, the [neonatal intensive care unit (NICU)] team had yet to arrive, and the infant was not breathing nor responding to the initial interventions," says Clifton-Koeppel. The ED team began to provide positive-pressure ventilation (PPV) to the infant with 100% oxygen via bag and mask.
There was not good chest expansion, and the newborn appeared cyanotic with a heart rate of about 80 beats per minute, says Clifton-Koeppel. "The ED team decided to intubate and begin PPV via endotracheal tube," she adds. "Immediately after intubation, the newborn’s color and heart rate improved. Slowly, the newborn began to breathe spontaneously."
If an NICU team is unavailable when a pregnant woman is about to deliver, Clifton-Koeppel says you should take the following steps:
1. Assess the infant’s breathing and color, and immediately place the infant on a radiant warmer to provide heat and access for assessment.
2. Clear the airway with a bulb syringe and gently stimulate to breathe.
3. Provide free-flow oxygen as needed. If the newborn has poor respiratory effort or is not breathing, provide PPV with 100% oxygen. Intubation is a consideration and should be performed if the newborn is extremely premature.
4. If the heart rate is less than 60 beats per minute, perform chest compressions along with PPV for 30 seconds. After 30 seconds of coordinated chest compressions and PPV, administer epinephrine via endotracheal tube or umbilical vein.
5. Reassess newborn for improvement in all parameters.
Resuscitation of the newborn outside the delivery room or NICU nursery should follow principles of the Neonatal Resuscitation Program, developed by the Dallas-based American Heart Association and the Elk Grove Village, IL-based American Academy of Pediatrics. These include providing warmth, positioning the newborn to promote an adequate airway, clearing the airway, stimulating the newborn to breathe, and giving oxygen as needed, says Clifton-Koeppel. "Assessment and interventions are performed simultaneously and quickly, such as establishing effective ventilation, providing chest compressions, and administering medications," she says.
The new algorithm for resuscitation of the newly born infant says the following key assessments should be performed first: presence of meconium, quality of breathing or crying, muscle tone, color, and term gestation, notes Michele Wolff, RN, MSN, CCRN, professor of nursing at Saddleback College in Mission Viejo, CA. She adds that the "first-level" interventions include: providing warmth, positioning and clearing the airway, drying, stimulating, repositioning, and providing oxygen as needed. "After these interventions, the infant’s heart rate, respiratory rate, and color should be assessed," says Wolff.
If the infant has apnea or a heart rate of less than 100 beats per minute, PPV should be administered, she adds. "If the heart rate remains below 60 beats per minute despite 30 seconds of airway support with 100% oxygen, chest compressions should be initiated," says Wolff.
Evaluation of respirations, heart rate, and color now occur simultaneously instead of sequentially, says Clifton-Koeppel. "This change emphasizes the importance of acting quickly if there is an abnormality in respiratory rate and effort, heart rate, or color," she says. Clifton-Koeppel says your initial assessment is based on five key questions:
- Is the amniotic fluid clear of meconium?
- Is the baby breathing or crying?
- Is there good muscle tone?
- Is the color pink?
- Was the baby born at term?
If the answer is "yes" to the above questions, the team provides routine care including providing warmth, clearing the airway, and drying, says Clifton-Koeppel. "If the answer is no’ to any of the above questions, the resuscitation team provides warmth, positions and clears the airway as necessary, dries, stimulates and repositions, and administers oxygen as needed," she adds. One of the quickest ways to determining the heart rate is to feel for a pulse at the base of the umbilical cord, where it attaches to the baby’s abdomen, says Clifton-Koeppel. "However, if the resuscitator is unable to obtain a heart rate in this manner, auscultation should be performed," she adds.
Palpation of the umbilicus is the preferred method, says Barbara Weintraub, RN, MSN, MPH, coordinator for pediatric emergency services at Northwest Community Hospital in Arlington Heights, IL. "This gives the nurse information not only about rate, as is obtained with a stethoscope, but quality of the pulse as well," she explains.
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