Monday, March 21, 2011

A typical day at work

I work as a newborn nurse at a busy, urban, level III NICU hospital.

Curious as to what I actually do? Read on:

(warning, long and detailed post!)

I really love my job. I am so lucky to have the privilege of meeting fresh new babies every day.

When I am the newborn nurse assigned to cover deliveries, this is what a typical day looks like: My job is to check equipment for function, stock supplies, and review prenatal records. I'll update neonatology as necessary (a neonatologist or neonatal nurse practitioner will attend any "high risk" delivery- breech, meconium stained amniotic fluid, prolonged decels on the monitor, any delivery less than 37 weeks gestation, insulin dependent diabetic mother, potential shoulder dystocia, compound presentation, vacuum or forceps, etc... ) and, of course, attend births!

When I first get to work, I will receive report for the previous shift RN about who is laboring-- any important medical history, how far dilated she is, how far along her pregnancy is, who her doctor is, etc. She will hand me the pager so that L&D can page me to an eminent delivery if I'm not on the floor.

If there aren't any women close to delivering, I will first go and check my equipment:
1.) make sure the neonatal code cart is locked and the transport isolette is stocked with an MIE bag and mask, full O2 and air tanks, has a full battery, and is pre-warmed to an acceptable temperature.
2.) check the two operating rooms and then all ten labor rooms for functioning wall oxygen/air and blender as well as functioning wall suction. I also check equipment in the warmer base drawers:
MIE bags and a full term and a premie O2 mask, suction catheters (two of each size- 14f, 10f, 8f, 6f), a stethoscope, 2 endotracheal tubes in all the following sizes: 2.0, 2.5, 3.0, 3.5, 4.0, laryngoscope blades (3 sizes) and handles, extra batteries for the handles, a MSAF kit (meconium aspirator, ET tube, stylet, and 14f suction catheter), CO2 detectors, OG tubes for lavage during codes, and of course diapers, hats, extra paperwork, tape measures, etc...
3.) check to make sure there are enough baby cribs in the closet
4.) check to make sure there are enough security sensors for our security system

In between all of this running around, I continually double check the labor board to see how far dilated our laboring moms are so I can try to manage my time efficiently. I will try to flag down the L&D charge nurse to get an updated report on any new admissions.

I will then flip through charts to review prenatal records for any pertinent data: full term?, Gravida/parity, age, relevant medical history, HBSAG and HIV status, rubella titer, blood type, urine toxicology results, etc. I will check to see if the mom will breast or bottle feed and who her pediatrician will be.

I will then try to make up identification bands for the baby... one less step to complete at the actual birth!

Usually all of this leg work gets "interrupted" by a birth or two. In this job, you've got to stay organized and be flexible!

If there are no births (rare!), then I go back up to the nursery to assist with assessments, teaching, admissions, blood work, charts, or anything else they might need.

Once I do get paged to a birth, I go into the room and set up my supplies. I like to have everything as ready as possible so that I can get all of my baby stuff done as fast as possible after the birth so I can hand the baby back over to the mom pronto. I will first turn on the radiant warmer to heat up, turn on my O2 and my suction, set up my baby blankets on the warmer, plug in the scale, set up my erythromycin with gauze and sterile water for cleaning the baby's eyes, draw up my vitamin k for the IM injection, get out an ink pad and a soapy gauze to clean the ink off, and get my transponder attached to a cord clamp. I get all my paperwork out and ready. As I'm doing this, I'm constantly assessing the situation in the birth room: is the fetal monitor on? How is the baby tolerating pushing contractions? Is the baby crowning yet? Will there be a vacuum or forceps? Do I need to page neonatology? Is there a nuchal cord? Is a tight cord clamped and cut before the birth of the body?

Once the baby is born, I hit the timer button on the warmer (for resuscitation purposes if necessary) and double check the time of birth. Most of the time, the baby is born with a lusty cry. If the baby is crying, I know that it has a good heart rate and good respirations. And I can relax a little and just let the mom enjoy her baby for a few minutes while the L&D nurse is stimulating and drying the baby on the mom's chest. After a bit, I'll ask the mom if its ok to borrow the baby for a few minutes... I'll take the baby over to the warmer and do a very quick assessment - pink? crying? good tone? Head to toe look-over. Then I'll ask the dad to get out his camera as I put the baby on the scale to get a quick weight and length. Back to the warmer. Vitamin K IM injection in the thigh, Erythromycin eye gel in the eyes. Complete the identification bands with the time of birth and sex of baby. Footprints. Have L&D nurse double check my ID bands before putting them on baby. Put security tag on baby. Finish measurements (head, chest, abdomen circumference). More thorough head to toe assessment with gestational age exam. Quickly write down anything out of the ordinary so I don't forget! Quick set of vital signs. Triple wrapped with hat (or SKIN TO SKIN with mom with warm blankets over both if she seems up for it). Hand baby to mother for breastfeeding!!!

All in all, I have baby at the warmer for 6-10 minutes before giving the baby back to mom. I'm usually so quick that I am finished with the baby before the mom's perineal repair is finished. I pride myself on being quick... many other nurses take as long as 25-30 minutes! That's a loooong time to be without your baby after birth! Some of these tasks must be done in the delivery room (footprints, bands, security tag, baby meds, vital signs) and the other things (gestational age exam and measurements) only take a minute to do and its really helpful to the nursery to get them done and it helps determine whether or not the baby will need to be on hypoglycemia protocol. Sometimes, if things are really crazy on the unit, I can omit these two things, but I often just throw it in anyway... it doesn't take long.

Once the baby's handed off to the mom, I help her with breastfeeding and tell her to hit the call light of she needs anything... then I clean up my mess (I usually just throw all my soiled linens and trash on the ground since I'm working so fast) and leave the room to finish paperwork. Charting takes a good 10 minutes to complete.

Then, I have to check vital signs on the baby every half hour (and check blood sugar if applicable) before bringing the baby up to the newborn nursery at two hours of age. This can become quite a busy task when there are multiple babies born on the floor!

There are obviously variations to this routine depending on the baby (Premature? Respiratory Distress? Immediate admission to NICU) or the delivery. In a c-section, I will have all of my equipment and supplies set out/turned on and then put on a sterile gown and stand near the sterile field next to the mom's legs. After the baby is removed and the cord is clamped and cut, the obstetrician will hand me the baby and I will take the baby immediately to the radiant warmer for drying, stimulation, and a quick head to toe assessment. If the mother is awake and seems interested, I will (if baby is stable), quickly wrap baby in a blanket and take him/her over to the mom for a minute so she can see the baby right away. I believe that this simple act goes a LONG way to help with bonding in cesarean deliveries. Oh, how I wish I could have seen my baby so soon after my c-section! Then, I'll return the baby to the warmer to complete my "tasks" before wrapping the baby and handing the baby off to the father. Unfortunately, I cannot leave the OR without taking the father and the baby with me (I am the one responsible for the baby), and if the unit is busy, I cannot linger for long. After 10 minutes or so, I lead the dad and the baby to the recovery room to wait for mom.

If the baby warrants some resuscitation, I follow NRP guidelines. Thank goodness, most babies only need a little bit of free flow O2 if anything at all. Thankfully, neonatology is always only minutes away and the L&D nurse is always there if I need a hand with resuscitation.

It is so amazing to have the honor of being in attendance at so many births. Although work is extremely busy and very physically demanding, I absolutely love it. I am hoping to constantly improve my practice to allow more skin to skin and sooner to facilitate bonding and early breastfeeding. I also hope to rub off on more nurses... I think I'm the only one who does this regularly!

My job is incredibly rewarding!

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