Full term grunting baby with good O2 sats

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Suppose you have the following situation:

1) Otherwise healthy full term baby born via uncomplicated c-section or lady partsl delivery, no meconium

2) Initial O2 sats in the mid 80s but improve to low 90s after about 2 minutes following delivery

3) Apgars are 7-9

4) Baby has good resp effort, minimal retractions, excellent color, and good O2 sats, but still has some mild grunting about 5-10 minutes out from delivery. HRs are consistently above 100, ranging between 120s-140s

What do you do in this situation?

1) Nothing. The baby is experiencing normal transitioning and may grunt for awhile. As long as the baby is vigorous and has good color, O2 sats, no bradys, then grunting is not a big deal.

2) Flow-by oxygen

3) CPAP or BiPAP (we use the neopuff devices for this purpose)

4) Bag mask ventilation

5) Intubation and ventilator

In our hospital, the L&D nurses are demanding that ALL babies who fit the above scenario get transported to the NICU immediately. They claim that a grunting baby 5 minutes after delivery is too dangerous and that the kid is crumping and needs either continuous CPAP or intubation.

So my question for you guys is this. How serious is mild grunting in an otherwise stellar full term baby approx 5 mins out from delivery?

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Specializes in NICU.

We would have our nurse practitioner come for a quick assessment. Assuming they agreed with the above findings, this baby would be transitioned in labor and delivery or newborn nursery on a warmer and monitor for one hour. If symptoms persisted at that time, the baby would be transferred to the Level II nursery for observation. This is mainly because the baby bears a little closer watching that our newborn nursery does not having the staffing to accomodate, and more little ones are being born who need to transition on that very same warmer. This baby is not "crumping" but just bears watching. Seems to me that immediate transport to the NICU is unwarranted, but it depends on the capabilities of your unit to transition babies. In my unit, CPAP or intubation (or any form of oxygen for that matter) would not be warranted in the above scenario. If the baby was unable to maintain oxygen saturations above 85, they would get oxygen by hood box. CPAP would only be used if the baby was unable to maintain saturations with oxygen, oxygen needs were fairly high, or the baby had a poor blood gas (which probably wouldn't be checked unless one of the two previous criteria was met...).

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Specializes in NICU, Infection Control.

IMO, the baby needs closer observation than the L&D nurse can provide. However that needs to happen in your facility, I think it should. The kid should go to a warmer, monitor (@least an oxymeter) and someone to keep an eye on it w/o having to worry about mom and her care needs @ the same time. If it's a c-section, they should be observed for a while anyway, they're more likely to get into trouble.

If s/he continues to exhibit distress, proceed w/septic w/u, cxr, IV, etc, etc.

If the baby does better, back to mom.

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This baby would have been monitored in our special care nursery for a short time, hopefully only the time it takes for mom to get out of the OR and PACU. The baby would have his/her head-to-toe assessment, Ballard, and bath. If he continued to grunt with the mild retractions, he would be placed on a CRM and pox, and closer observation to make sure he doesn't poop out.

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Specializes in NICU.

I do agree that the mom nurse should not be responsible for watching this baby closer. In our facility, the baby has their own nurse who is responsible for the baby. If the baby is doing well, they will spend time with mom and then go to the nursery for eyes and thighs, etc. But this baby, the baby nurse would be responsible for until resolved or until taken to the nursery for closer observation. The nursery generally should have staffing to accomodate a transition watch of one hour. If this is not feasible, baby worsens, or symptoms persist greater then an hour, then off to the special care nursery. But like I mentioned earlier, this depends on your facility routines and staffing for transitioning babies. If it is the responsibility of your special care nursery to transition, then the baby goes to SCN. But this baby does not warrant transfer to another facility, CPAP, or intubation!

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At our facility, there is no "transition" nursery. There's the L&D unit and there's the NICU and thats it. The L&D nurses insist that they are too busy to do anything for a baby, even just keeping a close eye on a baby who is transitioning over a 10 minute period is too much for them. If the baby has any grunting whatsoever, they wont even watch teh kid for 10 mins first, they demand an immediate NICU transfer.

IMO, a full term mildly grunting baby with good O2 sats and good apgars with no complications should be able to be taken care of by a standard L&D nurse for up to 20-30 mins after birth. Now if the baby is still grunting and not improving after 30 mins, then by all means ship him upstairs to the NICU.

I dont think its feasible at all to ship all these babies to the NICU after just 10 minutes post delivery. If we started that as policy, then almost 50% of all full term healthy babies would get sent to the NICU, because the bottom line is that its EXTREMELY common for healthy full term babies to grunt for awhile after birth as they transition.

I agree that the IDEAL setup would be for our hospital to have 3 units: L&D unit; "transitional" nursery where nurses only have to watch after babies and not their moms, and then a NICU. Unfortunately our facility does not have that setup. We have a state of the art, level III NICU and we have the L&D unit, and thats it. Full term babies who are mildly grunting 10 mins after delivery and havent fully transitioned yet dont need to be housed in a level III NICU with intubated kids and gastroschisis.

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Specializes in Community, OB, Nursery.

I'm on the side of those who say baby needs to be watched by someone other than L&D. If the L&D nurse is going to watch both mom AND baby, and baby bears close watching, even if temporarily, what is she to do if Mom starts crumping?

I realize that obsing babies in the NICU is a pain in the butt, but it's going to be a lot bigger pain in the butt to try and fix what might happen if L&D is watching the kid, gets distracted by a crashing mom (it happens) and the kid is one that's doing more than transitioning.

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Specializes in Level II & III NICU, Mother-Baby Unit.

Would it be possible for another mother-baby nurse to be "baby nurse" for a while as the mother's nurse takes care of mom? The issue seems too black and white... stay on the mother-baby unit or go to NICU. There needs to be a gray area for babies like these and the gray area is where another nurse monitors the baby closely for the first hour. It could be done in the Mom's room on a warmer if necessary I would think. I agree that a term baby who has had no prenatal or perinatal complications to indicate a potential problem is at hand can be expected to flare and grunt and be a bit tachypneic during the first hour of transition...that's why this time period has been given a name...transition. Put the baby on a sat monitor and watch it for 30 minutes to an hour; if it worsens then consult the nurse practitioner, get a gas and consider the NICU admission. Immediately sending a baby to NICU for normal transition issues is emotionally upsetting for the parents and we should not take this effect on their bonding lightly simply because a nurse doesn't want to or have time to watch over a new baby for an hour. Just my humble opinion... By the way, I've worked both Mother-Baby, Well Baby Nursery, Transition Nursery, and NICU in my career so I can understand both sides fairly well.

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I have often wonder what facilites with no nursery do with kids like this. I can see where the L&D nurse would not feel comfortable with a gunting baby when she has a mom that may hemorrage or a pt with decels in the next room. It's not fair to them.

However, it is not fair to the baby or the parents to wisk away a newborn that is transitioning to the NICU. It is scary for the parents, it interfears with bonding and/or breastfeeding, the baby will get a septic work up, and you just had a few thousand dollars added to your medical bill. All for a kid will most likely be fine in an hour or so or about the time we finish doing the LP and he screams his aveoli open.

There needs to a protocol in your facility for this type of pt if there is no nursery or OBS unit there.

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Specializes in NICU.

If the baby has just delivered, pink, cried appropriately but a little grunty when quiet (you know what I mean). Give the baby a chance, put it skin to skin on mom, and let the labor nurse watch it. If it's still grunty in 30 minutes, call me. We'll bring it back to the NI and monitor for 2-4 hours through transition. If things don't improve, they get a septic workup, comfort flow O2 progressing to whatever is needed.

The majority of babies improve within 30 minutes. We don't have a newborn nursery, vag deliveries go to pp 2 hours after delivery, and c/s babies go with mom to couplet care with an hour of the delivery, if we are not comfortable we keep the baby for that 2-4 hours.

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Specializes in NICU.

So, I'm just wondering... Does the baby not have a nurse at delivery? Is the labor nurse responsible for the baby from the moment of delivery? The baby should have a dedicated nurse at birth, and I don't think this means just until a five minute Apgar is achieved.

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