Could I have done more?

MA Nurse · Feb 4, 2007

Im a new nurse only three months exp on the floor of a low risk mother baby unit. I got a new admit to the floor a Csection mother and baby. Baby was checked out in NICU while mom came to me. After assessing mom I got baby from NICU, baby was pink, normal, with regular resps. While attempting to get baby to breastfeed baby spit up a small amt of fluid and blood, I assured mom this was normal from a C/S baby. Then an hour later after eating baby spit up a little more, baby was fussy so resps were elevated but no distress noted. At this point vital signs were due again in two hours. When I went back to the room, the room was ice cold. The family had turned the thermostat down to around 65. I immediately took baby vitals temp-96.5, p 140, resp 50, and baby wasn't breathing regular, I asked the mother how long the baby had been breathing this way and she said she didnt know and that the baby made some strange sounds and she thought about calling me but didnt. I pulled baby into the light and saw he looked different. I took baby to a charge nurse and said " look at this baby it isnt breathing right." The nurse looked over the baby and agreed and told me to go straight to the NICU and she would call ahead and let them know I was coming. When I got to the NICU the baby was turning blue, they immediately gave baby 100% oxygen. baby pulse ox was at 60, after oxygen it went to mid to high 80's. Then a team of nurses and neonatalogists went to work while I stood there trying not to cry. The neonatalogist pulled 7cc of blood from baby's stomach and believed it to be moms blood and told her that. However after x-rays turns out baby had a pneumothorax. I have a trillion questions racing through my head right now. If baby's pulse ox was 60 did I walk in right at the exact moment he was crashing? how long can organs survive with oxygen sats that low? Can a newborn live though this without suffering life long damage? how long does it take for a pneumothorax to develop in a neonate? Its hard for me to imagin that at the exact moment I walked in the NB was taking a turn for the worse. How long could a baby survive like this? seconds? minutes? hours? Was there something I missed in earlier assessment? I just dont know what to do, Im so upset.

I'm sorry for your experience. A lot of the nurses in my NICU are questioning care that was given to a baby that just died...so you're not the only one beating yourself up right now. Try to remember you checked on the baby when you were supposed to. The temp. was probably just because they had the room so cold. The resp. stuff you couldn't have prevented. The mom also should have called you if she was worried...they usually do!

It sounds like you rushed the baby quickly to get help. Have you checked on the baby lately? A pneumo can sometimes be caused from not getting that extra squeezing out of the birth canal because she had a C-section. Csection babies sometimes have resp. problems.

Don't beat yourself up. Let us know how the baby is.

Jolie, BSN · Feb 5, 2007

Your initial assessment revealed an apparently healthy, normal, transitioning newborn. Spitting up a small amount of bloody fluid is NOT abnormal in a newborn, whether C-section or lady partsl delivery. Remember that until a few hours ago, the baby was living in a fluid-filled environment with fluid-filled lungs, and that he probably swallowed a few mouthfuls on the way out. That is the most likely source of the baby's secretions.

In a low-risk mother baby setting, we are forced to rely on the parents to notify us promptly of changes in the baby's condition. If the child had been overtly cyanotic and gasping for breath, I'm sure the parents would have noticed and called for help. Most call for every little thing; few overlook obvious signs of distress. I suspect that you witnessed the early changes in the baby's condition, otherwise the parents would have been screaming for help in the hallway.

Now, on to your questions: The 7cc of bloody fluid pulled from the baby's stomach was most likely swallowed amniotic fluid and blood from delivery. Pulmonary bleeding, if it occured with the pheumothorax, would not likely be swallowed by the baby. So please don't worry about that. Pneomuthoraces (sp?) can occur spontaneously in otherwise healthy newborns, and are often discovered incidentally when chest x-rays are taken for unrelated reasons such as suspected fractures. They usually resolve with little intervention other than comfort and support measures and rarely cause any long term effects. There is nothing that you or the parents did to cause the pneumo, or could have done to prevent it.

The baby's poor color was likely due to cold stress as much as poor oxygenation. An O2 sat of 60% is certainly not desirable, but given the prompt attention the baby received, not likely to cause any long term problems, either. Remember that in utero, the fetal paO2 is only about 35. Neonates' brains and other organs are used to living in an oxygen-poor environment. Brief periods of oxygen deprivation in the immediate newborn period are not usually harmful in the long run.

The only thing I can suggest is more frequent monitoring of baby's temp. The need to assist newborns in thermoregulation is something most parents don't understand very well. They are often eager to undress and inspect the baby, which is fine under a warmer, but not OK in a cool room. They adjusted the room temperature to their comfort level, not understanding the baby's needs. Becoming hypothermic can have a cascading effect of complications in a newborn: Cold stress---increased glucose utilization---possible hypoglycemia---burning of brown fat---buildup of metabolic acids---increased demands on respiratory system---s/s of respiratory distress.

So, the simple act of maintaining warmth for the baby can help to prevent a number of possible complications. (Although the pneumo would have happened anyway, so don't beat yourself up over it.)

IvoryLena · Feb 7, 2007

Thanks for responding and explaining things to me, I feel much better now. Baby is still in the NICU but doing MUCH better and I saw mom who is doing well too. I check on him everyshift I work. At first he was on an oscillator, I think thats what they called it?, but now hes responding well to new treatment so they took him off it, but he's still on a vent but their trying to ween him off.

Jolie, BSN · Feb 7, 2007

Wow, he was one sick little puppy! That was definitely not a simple pneumo caused by pressure changes during delivery.

Has an infection been identified? Any indication of aspiration?

You did a good job of identifying his breathing problems and acting promptly to get him to a higher level of care.

Let us know how he does.

prmenrs, RN · Feb 7, 2007

I think you did well. Really well. I suspect the baby might have had a sepsis brewing @ birth. That can happen any time.

Mother-Baby nurses frequently have a significant pt. load. In California, the law states they are only supposed to have 4 couplets, 8 pts, on occasion, it gets higher. When I float over there, I usually get 6 babies. They're not all in one place, either.

I work ~ about 10 miles from the border. Our problem is moms [grandmoms, aunts, etc.] OVERdressing the baby. Socks, a onesie, a sleeper, receiving blanket, mitts, hat, and a BIG, thick, plush blanket over and under everything. Try taking a temp and changing a diaper w/all that on the kid!

Elvish, BSN, DNP, RN, NP · Feb 7, 2007

I work ~ about 10 miles from the border. Our problem is moms [grandmoms, aunts, etc.] OVERdressing the baby. Socks, a onesie, a sleeper, receiving blanket, mitts, hat, and a BIG, thick, plush blanket over and under everything. Try taking a temp and changing a diaper w/all that on the kid!

I work about 2000 miles from the border and still have that problem!!! I've found in talking c these moms that the reason they do that is either a) baby has a stuffy nose; or b) baby has those newborn neuro jitters and family takes that as a sign that baby is cold. So on go the 17 layers.

Back to the original topic, I agree c the posters who say you did everything you knew to do and intervened appropriately. That is the one thing about m/b nursing that laypeople (and me until I started working c babies) don't realize is that a good-looking kid can turn on you in an instant. Doesn't usually happen, but it surely can!