Grunting baby...

JenTheRN · Jul 13, 2011

Sometimes those 37 week babies need a bit more time to transition. Sounds like this one had some TTN (transitional tachypnea of the newborn). 92% on a newborn is not really that low, with some grunting and retractions it bears watching.

I would have let the charge nurse know, and asked her what she thought.

IMO, sometimes babies just need some time to transition, and unless they are in obvious distress, need to be left alone (so to speak) to do what nature has intended.

lrobinson5 · Jul 13, 2011

While maybe someone argued you could have waited, I think as a mom I would be more happy with what you did. If a nurse is worried then I probably would have wanted the doctor called.

Long Term Care Columnist / Guide · Jul 13, 2011

The term 'retractions' (spelled 'refraction' in the OP) scares me when it comes to little babies, because it indicates respiratory distress, and the grunting is NOT good. Tiny babies=tiny airways, and O2 sats don't always tell the whole story.

You were right to call the MD, regardless of what your charge nurse thought. Although I've worked mostly with folks at the other end of life, I've been around nurseries enough to have seen little ones decompensate so rapidly that it made my head spin. One minute you've got a baby who's breathing a little too fast and maybe got some nasal flaring, and 30 minutes later their sats are in the 70s and they've turned a ghastly shade of grey instead of a healthy pink.

As the parent of a now-grown child who once nearly died from respiratory problems, I say you can't really be too cautious when it comes to these little guys, especially when you're still new to the job. Good for you!!

BabyLady, BSN, RN · Jul 13, 2011

I'm a L&D new grad nurse...shy of 4 months to being a year. During my 4 months of orientation, I was oriented to our well baby nursery as well but was oriented to the nursery for ONE DAY. I feel so uncomfortable starting baby IVs, lab draw, even just monitoring.
I took care of a mom who delievered SVD and baby was 37 weeks, tachynpea intermittent with refraction. I took baby into the nursery to observe and another RN took over to recover my mom. Got MD's orders to observe for 2 hours. The last hour baby started grunting and O2 sat dec to 92%...I called MD and got orders for CRP, CBC, blood culture, IV for D10... boy, did this make my charge nurse mad.... it was 2 hours before change of shift and craziness begin on the floor. It changed the whole nurse patient ratio and my charge nurse was taking care of 4 patients and needed me back on the floor. Our scheduled induction had to be canceled because of we did not have enough morning staff to accomodate. I felt that everyone thought my baby was fine and should had not lab work up and an IV... I felt bad in a way, but my baby was grunting on and off... was I wrong? I was worried...

...I'm actually worried about something else.

That something as obvious as a blood gas and a chest x-ray was missed.

Did anyone do an assessment of how the lungs SOUNDED?

To me, this was a much more obvious course of action than a CBC and CRP. Because those were very unncessary labs if all the infant needed was a dose of surfactant and additional O2 to help it transition.

MD missed that...big time.

klone, MSN, RN · Jul 13, 2011

Were the grunting and retracting constant or intermittent?

My last baby was born at 36 weeks (little white boy, high altitude) and my nurse let him transition on my chest for about 3 hours with some blow by before they declared him.

I agree with a PP that with those late pretermers (or early term, as the case may be) you sometimes need to give them a bit more time to declare. Best place to transition is on mom 's chest, you could maybe strap on a pulse ox and give him a little blow by while he's transitioning. I also agre with a PP that one dip to 92 is nothing I would worry about. When he starts hanging out in the high 80s-low 90s consistently is when I would get concerned.

klone, MSN, RN · Jul 13, 2011

And I totally agree with Babylady - CXR should be done before cultures and IV. But that's just MHO as a non-physician

NicuGal, MSN, RN · Jul 13, 2011

Where I work, a grunting baby that lasts past 2 hours buys a work up and CXR. I don't neccesarily agree about just getting an xray before the cultures, but unless the kid's glucose was off, it wouldn't get an IV where we work until 4 hours. And we would never transition a kid on blowby on mom.

Sepsis and meningitis can have the same symptoms as RDS or TTN, so the blood work is necessary. Better safe than sorry. We just had a kid, kind of the same scenario who ended up with enterococcus meningitis...good thing that kid decided to grunt and need blow by because he would have been discharged and home before the real symptoms hit. If I were in your shoes, I would have reported it to, esp if he was grunting more than before. One must always CYA.

Unless we were there, I guess we really can't speculate too much. Does your hospital have an NICU, I am guess no because we would have had that kid at the NPO and IVF.

kessadawn, BSN, RN · Jul 13, 2011

I don't work L&D, but I do work PICU, and IMHO a grunting baby is NOTHING to fart around with. That newborn could have a cardiac issue, as well as all of the other things mentioned by previous posters, which is one reason an xray could have helped paint the picture, perhaps showing cardiomegaly.

Don't doubt yourself, you were concerned for the patient, the only thing I would have done different would be maybe to consult with the charge nurse before calling the doc. How did the baby fare?

retiredlady · Jul 13, 2011

After working in a nursery for a few years, I think that you did just fine. Baby probably retained some fluid, we would have done some chest percussion to get rid of the fluid, give flow by O2, checked the blood sugar (we had routine orders) and would call the doctor and he would usually order a chest X ray blood cultures, labs, and IVs or he would say observe for a while and call if it continued in a certain amount of time. Babies who are septic will grunt too, so it's better to be safe than sorry. After you are there awhile, you will be able to just look at a baby and know something is really wrong. You will be fine, hang in there.

BabyLady, BSN, RN · Jul 13, 2011

Where I work, a grunting baby that lasts past 2 hours buys a work up and CXR. I don't neccesarily agree about just getting an xray before the cultures, but unless the kid's glucose was off, it wouldn't get an IV where we work until 4 hours. And we would never transition a kid on blowby on mom.
Sepsis and meningitis can have the same symptoms as RDS or TTN, so the blood work is necessary. Better safe than sorry. We just had a kid, kind of the same scenario who ended up with enterococcus meningitis...good thing that kid decided to grunt and need blow by because he would have been discharged and home before the real symptoms hit. If I were in your shoes, I would have reported it to, esp if he was grunting more than before. One must always CYA.
Unless we were there, I guess we really can't speculate too much. Does your hospital have an NICU, I am guess no because we would have had that kid at the NPO and IVF.

I couldn't disagree with you more.

A chest X-ray for a kid with respiratory issues can instantly tell you what the ptoential problem is. Any kid in my unit, if blow-by and PPV doesn't transition, the next step is chest x-ray with a blood gas and surfactant (only if a chest x-ray shows evidence it is needed). Both of these can be done in less than 15 minutes.

A CBC, CRP and Cultures are not drawn unless GBS status is unknown or other issues with the material history... To me, if you have a mother who is GBS negative, otherwise infection free, uneventful delivery, good prenatal care and a kid that exhibits RDS?

No Neo here would go with something more invasive unless the most obvious cause is treated first...again, if blood gas and chest x-ray warrants it.

Jolie, BSN · Jul 13, 2011

...I'm actually worried about something else.
That something as obvious as a blood gas and a chest x-ray was missed.
Did anyone do an assessment of how the lungs SOUNDED?
To me, this was a much more obvious course of action than a CBC and CRP. Because those were very unncessary labs if all the infant needed was a dose of surfactant and additional O2 to help it transition.
MD missed that...big time.

I agree that a CXR and blood gas are important aspects of a comprehensive work-up to make a differetial diagnosis of TTN vs. RDS vs. possible sepsis vs. possible cardiac abnormalities.

But it concerns me that (maybe I'm misinterpreting your post) that your unit would consider a "dose of surfactant...to help" a baby "transition" especially without having ruled out sepsis as a cause of the baby's symptoms.

Is easing transition an acceptable use of surfactant? If so, what would the criteria be? A particular O2 requirement? Would the baby be temporarily intubated solely for surfactant administration, then placed on a cannula?

I realize that I'm a relic, but I always understood surfactant to be reserved for infants with RDS requiring mechanical support.