[htrn]

Was baby nurse on a delivery last week and have been unable to get this out of my head since then... HELP

This delivery had no risk factors, GBS neg, 4 hours ROM, no temp, etc... MD used a vacume atleast 5 times with atleast 3 pop offs and I'm sure will dictate that she kept the pressure in the 'green range' for all pulls

Anyway, came out fine - apgars 8/9, off for color. Did have a nuchal cord X 4 , but nothing to indicate that with FHR decels PTD. Had a significant cone head, but did well. Gave him to mom to hold after 5 minute apgar and Deleeing him of 2mls. At 15 minutes of life, the delivery nurse brought him back to the warmer and said he looked a little pale, which he did. Cap refil of about 4 seconds. Gave him blow by O2 and stimulated him - rest of VS were fine (TPR).

At this point I took him back to the nursery and slapped a pulse ox on him, low 90s so continued blow by, did another set of VS, did CS (104) and called MD on call. She said he probably was just stunned from vacume head, I'm thinking volume depletion into a cone head, but OK. Just continue blow by, get a sheep skin for his head and watch, wean from O2.

About 30 minutes later, he's all over the warmer (little squirmy dude) and crying because his head hurts (I think anyway). We DCd blow by as his sats came up to 98-100% on room air. About 10 minutes later his RR went up a little (70's-80's) but that was with crying. Rest of VS OK, next CS was 102 (20 minutes after 1st).

At this point it is about 0700 and I called the pediatrician that would be following this kid, not the same one that was on call thirty minutes ago, to let her know about the delivery. She goes off, why isn't he on blow by anymore.... start blowby now and I'll be in after I eat my breakfast

I give report, have restarted blowby, etc... All other VS are fine, just a little 'comfortably tachypnic" Pediatrician calls back and orders a stat CXR to make sure he hasn't blown a pneumo...

On coming nurse sticks a lemon glycerin swab in his mouth and re-situates him in the warmer, RR comes down to 52. MD walks in and orders hood O2 NOW - and now the day nurse is saying his RR is this and his O2 sat was 98-100% on RA - do you still want hood. I could tell she was trying to stall long enough for ped to - well, anyway

Sorry for the long rant, did I under react or did MD over react - would love some feedback

[Jolie]

Originally Posted by obrnheather

Was baby nurse on a delivery last week and have been unable to get this out of my head since then... HELP

This delivery had no risk factors, GBS neg, 4 hours ROM, no temp, etc... MD used a vacume atleast 5 times with atleast 3 pop offs and I'm sure will dictate that she kept the pressure in the 'green range' for all pulls

Anyway, came out fine - apgars 8/9, off for color. Did have a nuchal cord X 4 , but nothing to indicate that with FHR decels PTD. Had a significant cone head, but did well. Gave him to mom to hold after 5 minute apgar and Deleeing him of 2mls. At 15 minutes of life, the delivery nurse brought him back to the warmer and said he looked a little pale, which he did. Cap refil of about 4 seconds. Gave him blow by O2 and stimulated him - rest of VS were fine (TPR).

At this point I took him back to the nursery and slapped a pulse ox on him, low 90s so continued blow by, did another set of VS, did CS (104) and called MD on call. She said he probably was just stunned from vacume head, I'm thinking volume depletion into a cone head, but OK. Just continue blow by, get a sheep skin for his head and watch, wean from O2.

About 30 minutes later, he's all over the warmer (little squirmy dude) and crying because his head hurts (I think anyway). We DCd blow by as his sats came up to 98-100% on room air. About 10 minutes later his RR went up a little (70's-80's) but that was with crying. Rest of VS OK, next CS was 102 (20 minutes after 1st).

At this point it is about 0700 and I called the pediatrician that would be following this kid, not the same one that was on call thirty minutes ago, to let her know about the delivery. She goes off, why isn't he on blow by anymore.... start blowby now and I'll be in after I eat my breakfast

I give report, have restarted blowby, etc... All other VS are fine, just a little 'comfortably tachypnic" Pediatrician calls back and orders a stat CXR to make sure he hasn't blown a pneumo...

On coming nurse sticks a lemon glycerin swab in his mouth and re-situates him in the warmer, RR comes down to 52. MD walks in and orders hood O2 NOW - and now the day nurse is saying his RR is this and his O2 sat was 98-100% on RA - do you still want hood. I could tell she was trying to stall long enough for ped to - well, anyway

Sorry for the long rant, did I under react or did MD over react - would love some feedback

Mt vote is that the ped over-reacted.

The baby had some mild difficulty transitioning. No surprise given the scalp trauma he experienced. You were monitoring him closely, and adjusted the FiO2 accordingly.

To place a baby with 98-100% O2 sats under a hood is absurd. Not only do you risk retinal damage, you will certainly make the poor tyke miserable and interfere with bonding. His crying will increase his respiratory rate, causing the pediatrician to hold feedings and order an IV. Treating a child unnecessarily can lead to lots of avoidable complications.

[darynash]

The doc overreacted. I think your assessment was correct. His head hurt. We need to be careful giving O2. We are so used to giving it indiscriminately and we now know that the free radicals that are released actually cause tissue damage. Doesn't sound like the OB was doing the right thing either.

[dawngloves]

Just sounded like he had trouble transitioning and recovered well.He did not warrent O2 w/sats <95%. And it is not within NRP guidelines to give blow by to that kid, especially if it was 100%.
I am confused about the glycerin swab. What is the rationale behind that?

[KRVRN]

Ped overreacted. A hood would have been warranted if the baby had blown a pneumo but until you know that I don't see much reason to put one on or give blow by. Hey, he could have been tachypneic from pain right? Or TTN or hunger.

I think maybe the lemo swab was to calm him down, right? Because it's flavored he'll suck on it? (too bad you couldn't slip him a binky)

[htrn]

The lemon glycerin swab was to help calm him down. We have been giving them to our little guys during circs too. Kiddos seem a little more interested in them then pacifiers when they are really ticked.

This baby did end up in hood for several hours. He did end up having a sl. enlarged heart that showed up on the CXR and a funky EKG they did right after I left that morning. I still don't know why the ped thought these tests needed to be done in the first place - but in the end, I'm glad they were.

Now my issue is - what the heck did I miss??? I still haven't been able to tease out that information from the nurses that took over for me nor have I seen that pediatrician again. I was told that he 'acted like a heart kid' and seemed to take quite a long time to bring his sats up once he was put under the hood, but he never had low sats for me. I am soooo confused.


Thanks for all the responses - it helps to have a sounding board.

[KRVRN]

Well, you don't necessarily give O2 to a heart kid...

Let us know what you find out!

[MIA-RN1]

reading this thread w/ interest--
what is a C/S? (I am thinking its prolly something I know but call something else and can't place it)
And is volume depletion r/t conehead something really serious? I had never heard of it and am thinking one I had last night w/ real cone head, overlapping sutures and 1.5 wks post-date who wouldn't latch, root, or really wake up for the 8 hours I had her. Just curious.

[cjohn99]

I'm just a Student nurse but I assume the cone head was a possible Cephalohematoma due to the vacuum extraction. The baby will have to be assessed for hyperbilirubinenmia also.