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.


Carrie said...

My husband was allowed into the NICU as soon as they took our son (28 weeker). I was still delivering the placenta. When they were trying to place an iv, my husband about passed out. I can understand why some NICU's would like parents to wait some time before letting parents in

Judy said...

I have started IV's with parents in the room, but most are uncomfortable staying for heelstick blood draws. The only time a dad nearly passed out on me, I wasn't even doing anything to his baby.

Sarah M. said...

Huh. My husband walked down to the NICU with our 24 weeker and stood there while they worked on stabilizing her. And I once helped a nurse start an IV in her. And we were at an extremely large hospital. I wonder if it's just policies differing from place to place?

And something I've realized after getting out of the NICU, from the parent's side of things - sheltering parents from blood draws doesn't really help them in the future when they are expected to hold their kids down ;) I can't count the # of times after getting discharged I've had to hold my daughter down for an IV...

I guess though for your average, say, 34 weeker, they aren't going to have nearly as many IV sticks and blood draws in the future as my daughter, though. LOL!

Judy said...

Visiting policies can be quite variable from place to place. My husband has been hospitalized in a nearby large university hospital where they wanted me to step out of the room while they did something. Sometimes I did, sometimes I didn't.

At another hospital they even considered asking me to start his IV when they had a hard time getting it. That's definitely not typical, but if the second nurse hadn't gotten the IV, I would have done it.

I'm more comfortable with having parents present for some types of procedures than some of my co-workers. I don't ask parents to leave for blood draws, I ask if they prefer to leave. Most do at first, but gradually become more comfortable with watching procedures.

Eventually most parents realize that they can hold the pacifier or the baby's hand to comfort them during the blood draw. Until they're ready to do that, I'm not going to risk having a parent faint by asking them to stay for something that makes them uncomfortable.

I would never insist that a parent restrain a child for a painful procedure -- and I've never been asked to help restrain my own child. I'd much rather get another staff member and leave the parents free to comfort the child. I realize that there are situations where that isn't an option, though.

Anonymous said...

With the exception of the X-rays, can I ask why these procedures can't be done while you keep mother and baby together?

Judy said...

We have to transport the baby from the birthing center (delivery room) to the Neonatal ICU quickly in order to maintain the baby's temperature -- especially if the baby is premature and/or small. It isn't practical to do these things in the birthing center. Those rooms are set up for healthy term babies.

We usually move the baby while the OB is delivering the placenta or checking the mom out after delivery, or in the case of a C-section, closing the incision (sometimes before).

Moms who have had a vaginal delivery are usually ready to come to the NICU about the time we're ready to receive them. Moms who have had a C-section or who are not medically stable themselves may not be able to come to the NICU for hours or days.

The father and other family members could come, but it is not our policy at this time to permit that. Our unit isn't one of the largest, so space is an issue.

With some procedures, preventing infection is also an issue. For the rest, it's primarily a matter of the comfort level of the practitioners and concern for the potential reaction of a parent we do not yet know while invasive procedures are being performed on their infant. We simply aren't staffed to deal with a panicky parent in the middle of a resuscitation.

There are hospitals with different policies. Sarah says her husband was permitted to stay while their 24 week preemie was stabilized. She mentions that this was at a very large hospital.

After the initial stabilization, it's more common to have parents present during procedures or testing. Unless a procedure includes a significant risk of infection (like placement of central IV access) it's a question of their comfort and the comfort of the staff member performing the procedure.

abrander said...

When we had our first child in week 27, I (the dad) followed our son to the NICU when they left the birthing center. They gave me very quick instructions (do NOT touch anything etc) but I saw everything happening to our child. The procedure took 4 minutes btw! I was quite impressed :)

Then they took a digital photograph of our baby and printed it right away. I was given that photograph and were sent back to my wife, to show her our son while she was recovering from giving birth. I think that was a great way to deal with parents. I knew the whole time where my baby was, and I knew who we're handling it. I was back to my wife within 15 minutes with the newly printed picture. An hour later or so she was ready to visit the NICU.

Generally they did I really good job of involving the parents. We we're housed in a (very small) one room apartment right at the NICU where we stayed for two monts with our child.

(I don't know if it was a large or small hospital. It was in a small city in Denmark and I think they had room for about 20-30 babies in the NICU)

Judy said...

20-30 is mid-sized NICU. Large enough to have lots of experience with many kinds of neonatal problems, not so large as to be overwhelming. Large NICUs have their place, too and some things can only be managed in the larger NICUs

Very nice for you that they had a place for you to stay near the baby. Most of our families are local (live within 15 minutes), but a few are from farther away and the nearest accommodation for families is about 30 minutes from us.