NIGHTINGALE INSTITUTE OF NURSING,

NOIDA

ASSIGNMENT
ON
ORGANISATION OF NEONATAL CARE, TRANSPORT AND
MANAGEMENT OF NICU
(SUBJECT: OBSTETRICS AND GYNAECOLOGY)

SUBMITTED TO : SUBMITTED BY:

Ms. FINU MAM Ms. RUPALI ARORA
LECTURER MSc(N) 1 ST YEAR

DATE:
 TABLE CONTENT
1. Introduction
2. Definition
3. Aims/goals of NICU
4. Objectives
5. Indications for admission in NICU
6. Basic facilities
7. Components to be consider while organising an NICU
a. PHYSICAL FACILITIES
b. PERSONNEL
c. EQUIPMENTS
d. LABORATORY FACILITIES
e. PROCEDURE MANUAL
f. TRANSPORT OF SICK INFANTS
g. COOPERATION BETWEEN THE OBSTETRICIAN AND NEONATOLOGIST
8. Towards gentle and friendly NICU environment
9. Conclusion
10. Bibliography
 INTRODUCTION

New born intensive care approach developed from the concept that a more intensive approach to neonates who
require special care would result in a significant decrease in neonatal mortality and morbidity.

A neonatal intensive care (NICU) is an intensive care unit specializing in the care of ill or premature new born infants.
The first official NICU for neonates was established in 1961 at Vanderbilt University Mildred Stahlman, officially
termed as NICU when Stahlman used a ventilator off label for a baby with breathing difficulties, for the first time
ever in the world.

DEFINITION

New born or neonatal intensive care unit, an intensive care unit designed for premature and ill new born babies.
Andria Santiago

NEONATAL CARE The management of complex life threatening diseases, provision of intensive monitoring and
institution of life sustaining therapies in an organized manner to critically ill children in a separate pediatric intensive
care unit.
 AIMS/GOALS OF NICU

The goals of neonatal intensive care unit are

 To improve the condition of the critically ill neonates Keeping in mind the survival of neonate so as to reduce
the neonatal mortality and morbidity
 To provide continuing in-service training to medicine and nursing personnel in the care of new born.
 To maintain the function of the pulmonary ,cardiovascular, renal and nervous system.
 To monitor the heart rate, body temperature, blood pressure, central venous pressure and blood by non-
invasive techniques.
 To measure the oxygen concentration of the blood by oxygen analysers.
 To check /observe alarms systems signal, to find out the changes beyond certain fixed limits sets on the
monitors.
 To administer precise amounts of fluids and minute quantities of drugs through I.V infusion pumps.

OBJECTIVES
 To save the life of the sick new born
 To prevent damage in infants with problems at birth and also reduce morbidity in later life.
 To monitor high risk new born so as to reduce mortality and morbidity in these babies.

INDICATIONS FOR ADMISSION IN NICU

1. Low birth weight

2. Large babies
3. Birth asphyxia
4. Meconium aspiration syndrome
5. Severe jaundice
6. Infants of diabetic mother
7. Neonatal sepsis
8. Neonatal convulsions
9. Severe congenital malformation
10. Oxygen therapy/parental nutrition
11. Immediately after surgery
12. Cardio respiratory monitoring
13. Exchange blood transfusion
14. Mother of hepatitis b carrier
15. Injured neonate
16. PROM/foul smelling liquor
 BASIC FACILITIES

• Adequate space

• Availability of running water

• Centralized oxygen and suction facilities

• Maintenance of thermo- neutral environment

• Availability of plenty of linen and disposables

• Facilities for availability to treat common neonatal problems

MAIN COMPONENTS TO BE CONSIDER WHILE ORGANIZING A NICU

 PHYSICAL FACILITIES
 PERSONNEL
 EQUIPMENTS
 LABORATORY FACILITIES
 PROCEDURE MANUAL
 TRANSPORT OF SICK INFANTS
 COOPERATION BETWEEN THE OBSTETRICIAN AND NEONATOLOGIST

PHYSICAL FACILITIES
•Location •Space •Floor plan •Lighting •Environmental
temperature and humidity • Handling and social contacts • Communication
system • Acoustic characteristics

• Ventilation • Electrical outlet

LOCATION:
• Located as close as to labour room and obstetric care unit

• Adequate sunlight for illumination

• Fair degree of ventilation for fresh air

SPACE:
 serve as a referral unit for the infants born outside the hospital
 Each infant should be provided with a minimum area of 100 sq. ft. or 10sq. meter
 Space for promotion of breast feeding
 500-600 Gross square feet per bed.
 Space includes patient care area, storage area, space for doctors, nurses, other staff, office area, seminar
room area, laboratory area and space for families
 6 Feet gap between two incubators for adequate circulation and keeping the essential lifesaving equipment

FLOOR
PLAN
 Open encumbered space
 The walls should be made of washable glazed tiles and windows should have two layers of glass panes.
 Wash basins with elbow or floor operated taps facility having constant round-the clock water supply should
be provided.
 The doors should be provided with automatic door closers.
 Isolation room

VENTILATION:
 Effective air ventilation
 Central air conditioning

LIGHTING
 The whole unit must be well illuminated and painted white
 The lighting arrangement should provided uniform shadow-free, illumination of 100 foot candles at the
baby’s level

ENVIRONMANTAL TEMPERATURE AND HUMIDITY

• The temperature inside the unit should be maintained at 28’ +_2’C, while the humidity must be above 50%.

• Portable radiant heater, infrared lamp can be used

ACOUSTIC CHARACTERISTICS
• The ventilation system, incubators, air compressors, suction pumps and many other devices used in the nursery
produce noise.

• Sound intensity in the unit should be exceed 75 decibels

. • Telephone rings and equipment alarms should be replaced by blinking lights.

COMMUNICATION SYSTEM:
• The unit should also have an intercom & a direct outside telephone line

ELECTRICAL OUTLETS
• Each patient station should have 12 to 16 central voltage – stabilized electrical outlets sufficient to handle all
pieces of equipment

• An additional power plug point

• There should be round-the-clock power back up including provision of UPS system

 STAFF / PERSONNEL
 A direct who is a full time neonatologist
 One neonatal physician is required for every 6-10 patients
 One resident doctor should be present in the unit round-the-clock.
 Anesthetist, pediatric surgeon and pediatric pathologist are essential persons in establishment of a good
quality NICU

NURSES

 A nurse : patient ratio of 1:1 maintained thought out day and night is absolutely essential for babies on
multi system support including ventilatory therapy.
 For special care neonatal unit and intermediate care, nurse to patient ratio of 1:3 is ideal but 1:5 per
shift is manageable.
 Head nurse is the overall in-charge
 In addition to basic nursing training for level-II care, tertiary care requires, staff nurse need to be trained
in handling equipment, use of ventilators and initiation of life-support like use of bag and mask
resuscitation, endotracheal intubations, arterial sampling and so-on.
 The staff must have a minimum of 3 years work experience in special care neonatal unit in addition to
having 3 months hand- on-training in an intensive care neonatal unit.

OTHER STAFF

• Respiratory therapist • Laboratory technician

• Public health nurse or social worker • Biomedical engineer • Clark

DISPOSABLE ARTICLES REQUIRED FOR THE NICU

•IV Catheters •IV sets •Micro burette sets •Bacterial filters •Feeding tubes
•Endotracheal tubes •Suction catheters •Three-way stopcocks •Extension tubing
•Umbilical arterial and venous catheters •Syringes, needles
 EQUIPMENTS
 Resuscitation set -6
 Open care system 4
 incubators -2
 infusion pumps -12
 +ve pressure ventilators -6
 o2 hoods, 02 analysers -6
 Heart rate apnoea monitors without scope-6
 Phototherapy unit-6 –
 Electronic weighing scale-12
 Pulse oximeters -6
 Transcutaneous PO and PCO2 monitors 2-3.
 Non-invasive B.P. monitors 4-2.
 Invasive RP. monitors 1-2
 ECG monitor without defibrillator -1
 Intracranial pressure monitors -1.
 Radiant warmer

LABORATORY FOR NICU

 A micro chemistry laboratory attached to the unit and providing round the clock service, in
preferable through under Indian conditions, this may not be mandatory.
 This should be well-equipped to provide quick and reliable haematocrit, blood glucose and total
serum bilirubin.
 Facilities for total leukocytes counts and microscopic examination of peripheral blood films for
evidence of infection.
 Equipment for measure of specific gravity of urine and calcium should be available.
 House X-ray machine and an ultrasound machine should be mandatory for modern day neonatal
care units.
 BABY CARE AREA

• Areas and rooms for inborn or intramural babies

• Examination area

• Mother’s area for breast feeding and expression of breast milk

• Nurses station and charting area.

HAND-WASHING AND GOWNING ROOM:

Should be located at the entrance.

self closing doors.

LEVELS OR GRADES OF NEONATAL CARE
•Level I

•Level II

•Level III

LEVEL I CARE

•The minimal care

•Provided by the mother under the supervision of basic health professionals.

• Neonates weighting more than 2000 gm or having gestational age maturity of 37 weeks or more belong to this
care.

•This care can be include care of delivery, provision of the warmth, maintenance of asepsis, and promotion of
breast feeding.

LEVEL II CARE

•This care includes requirement for resuscitation, maintenance of thermo-neutral temperature, intravenous
infusion, gavage feeding phototherapy and exchange transfusion.

•10-15 percent of the new born require this care

• This care is anticipated for the infants weighing in between 1500 & 1800 gm or having gestational age maturity of
32 to 36 weeks.

LEVEL III CARE

•This care includes lifesaving support system like ventilator and best suited special intensive neonatal care.

•Three to five percent of new born require care of this level.

•This level of care is for critically ill babies, for those weighing less than 1500 gm or having gestational age maturity
of less than 32 weeks.
 TRANSPORT OF NEONATES
A significant number of neonates require emergent transfer to a tertiary care centre, often because of
medical, surgical, or rapidly emerging postpartum problems. These are termed “outborn” neonates,
because they have been born somewhere besides the facility to which they’ve been transferred.
• Transfer can be within the hospital; to ICU
• Transfer can be to other hospital
Neonatal transfer types
• Emergency: unplanned
• Elective : planned and informed
How can we transfer?
• The short distance transport within the hospital can be accomplished in a transport incubator.
• The use of plastic basket with perforated sides coupled with careful placing of hot water bottles is
recommended for use in the rural setting.
• The baby can be wrapped in tin foil or covered with several layers of cotton.
• Thermocele (polystyrene) box is an effective insulator and can be used in community
• Skin to skin contact with mother or a care taker is a useful modality of transport in rural areas or
resource poor settings.
Indications of neonatal transport
• Preterm infant with a birth weight <1500g or gestation <32 weeks
• Respiratory distress requiring CPAP or assisted ventilation
• Severe hypoxic-ischemic encephalopathy
• Life threatening sepsis
• Intractable seizures
• Bleeding neonate
• Congenital anomalies or surgical neonate
• Inborn errors of metabolism
• Severe jaundice
• Procedures or diagnostic facilities unavailable at parent hospital.

Transport equipments
1. Transport incubator with multi channel vital signs monitor for recording temperature, heart rate, NIBP,
oxygen saturation
2. CPAP facility with nasal prongs and portable ventilator
3. Airway equipment: suction devices, oral airways, bag and mask, laryngoscopes (size 00,0 and 1 blades)
4. Infusion facilities: infusates, infusion pumps, glucometer
5. oxygen, compressed air cylinder, oxygen mask, hood, heat and light, sources of electric powers and
adapters.
6. disposables: catheters (5,6,7,8,10,12Fr), syringes, needles, feeding tubes (8 & 10Fr), alcohol, betadine
swabs, micropore tape, gloves etc.
7. Instrument tray for ET intubation, vascular access, insertion of chest tubes, NG tube etc
8. Life saving drugs
Transport team
• The neonate needing special or intensive care should be transported by a skilled transport team.
• Teams include at least, a) One senior resident b) One specially trained neonatal nurse

Protocols
a. Maintain airway, oxygenation, thermal stability and tissue perfusion
b. Stop oral feeding and start parenteral feeding with 10% of dextrose.
c. Ensure umbilical or peripheral venous access
d. Insert an NG tube and decompress the stomach
e. Maintain adequate blood glucose level
f. Obtain culture samples and administer first dose of antibiotics.
g. Obtain a recent chest skiagram as a base line and to check the position of catheters and
tubes.
h. Take the family member or parents along with the baby whenever feasible.
i. When required transport team should undertake life saving procedures (like ET tube
insertion, chest tube insertion etc)
 j. administer life saving drugs like surfactant and prostaglandins
k. The referring hospital should prepare a detailed transport note including copies of obstetric
and neonatal charts for the transport team.
l. Monitor the baby’s color and temperature.

Arrival and receiving at NICU

• The transport team should remain in constant touch with the referral NICU during the course of journey.
• The team should brief the NICU care givers regarding the status of the baby and immediate clinical
concerns.
• Hand over all the documents.
• The referring hospital and parents should be informed about the safe arrival and latest condition of the
baby.
• The inventory of transport equipment should be checked, medications and essential supplies should be
restocked for the next transport service.
TOWARDS A GENTLE AND FRIENDLY NICU ENVIRONMENT
•It has been realized that physical and social environment of nursery affect the recovery and long term morbidity of
the neonate.

•Attempts should be made to reduce unnecessary noise and light.

•Avoid excess of light

•Handling should be gentle

•Neonates including pre terms feel pain and painful stimuli can cause deleterious physiological responses. Analgesia
should be provided during all procedure including ventilation.

•Parent should be allowed unrestricted entry to the nursery.

•They should be explained about various tubing and attachments to the baby and should be involved in care of their
baby.
 CONCLUSION
A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit (ICU)
specializing in the care of ill or premature new born infants. Neonatal refers to the first 28 days of life. Neonatal care,
as known as specialized nurseries or intensive care, has been around since the 1960s.

The first American new born intensive care unit, designed by Louis Gluck, was opened in October 1960 at Yale New
Haven Hospital.

NICU is typically directed by one or more neonatologists and staffed by resident physicians, nurses, nurse
practitioners, pharmacists, physician assistants, respiratory therapists, and dietitians. Many other ancillary disciplines
and specialists are available at larger unit.

Its very important to manage and organise the nicu in a well way to give protective and safe environment to the
newly born babies in order to overcome any health issues.

though NICU services require high technology input and expensive one should not lose sight of the human approach
towards the fragile and sick babies & their anguished parents. To obtain best results from neonatal intensive care we
need a well equipped unit.

BIBLIOGRAPHY