Thursday, June 05, 2008

Welcome to the NICU, let me show you around - Part II

Why do I have to wait so long to come see my baby?

Parents may be asked to wait 30 minutes to an hour - occasionally longer - as we admit the baby to the NICU. Other units may have different policies, but we find it easier to provide urgently needed care if we can explain it to the parents when we've finished, rather than during the procedures. Some of them can be frightening if you've never seen them before. If the mom arrives at the hospital several hours (or days) prior to delivery, our physicians or nurse practitioners will spend some time explaining the NICU admission procedures and what we expect for their baby. Unfortunately, we don't always have this opportunity.

A-B - Airway & Breathing. If the baby is having difficulty breathing, or maintaining an adequate oxygen level, we'll have to deal with that. Sometimes the problem is so severe that we need to place a breathing tube in the delivery room. Sometimes the baby just needs some supplemental pressure or oxygen.

If the baby just needs a little oxygen (bigger babies who are simply slow transitioning), we may use a nasal cannula -- just like the ones used for adults, but smaller. Humidified, and sometimes heated (depending on the flow) oxygen is provided. We use a device called a blender to mix it with air to provide just the right concentration for each baby.

Babies who need more help breathing may be placed on Continuous Positive Airway Pressure -- which we call CPAP (pronounced See-pap). Humidified, heated air mixed with oxygen (again, a blender) is delivered at a higher flow to a nasal mask which covers the nose or soft "prongs" that fit inside the nostrils. This is similar to the equipment used by adults with sleep apnea.

Babies in severe respiratory distress will have a breathing tube placed. The tube is called an endotracheal tube or ET tube and the procedure is called intubation. Babies who are intubated usually receive surfactant. Surfactant is the substance in your lung fluids which decrease the pressure needed to expand the lungs -- and decrease the effort needed to breathe. We use a natural (animal derived) surfactant rather than a synthetic surfactant because studies have shown better outcomes with the natural surfactants.

Once the baby's airway is stabilized - with one of the above - we'll need an xray to check the extent of lung disease and the placement of that ET tube.

C - for Circulation. If the baby requires full resuscitation at delivery, we will provide chest compressions and possibly some fluid in the delivery room. Most babies don't need that degree of resuscitation at birth, but it is far more common for babies to have abnormally low blood pressure for many reasons which can range from blood loss due to placental separation prior to birth to septic shock from infection. We may start an IV in the baby's arm or leg, but if the blood pressure is very low or if the baby requires an ET tube to breathe, we'll probably place catheters in the baby's umbilical cord.

The doctor or nurse practitioner will tie a sterile cord around the base of the cord to keep it from bleeding. Then they will place a flexible tube into the umbilical vein and one of the umbilical arteries. This gives us a place to provide needed fluid, a way to obtain blood samples without using needles, and a way to monitor the baby's blood pressure more accurately. Again, an xray will be needed to determine the placement of those catheters. On a good day, we get one xray for ET placement and line placement at the same time.

Babies who aren't so sick will have a thorough physical exam and some basic lab work, possibly an IV placed in an arm or leg, and an xray. Families of those babies usually get to visit within about a half hour. If things seem to be taking an unusually long time, the nurse from the delivery room can call the NICU to find out what is holding things up -- it may be an emergency with another baby. Occasionally we admit 2 or even 3 babies at the same time -- and that's not counting the twins and triplets. Larger NICU's in hospitals with busier delivery suites are likely to be even busier.

Once the baby's condition is stabilized and the urgently needed procedures are completed, we let the nurse in the delivery suite know so the family can come visit the baby.