Pediatric Village Delivery Orientation

Preparing to go out for a village delivery

• Get information about prenatal history and risk factors for baby
• Coordinate with Family Medicine (FM) physician activating the medevac and the Lifemed crew about when to meet at the hanger. You can drive or take a cab separately or together to the medevac hanger at 3600 Tower Road (next to old ACE Hanger). Get door code in case you are taking a cab and no one is at the hanger yet.
• Have FM physician staying behind assume Tiger Text ‘Peds Wards On Call’ role
• Make sure you have warm clothing/appropriate gear, snacks, drinks, money etc. There is some small/medium women’s warm gear and boots on and next to the coat tree next to peds hospitalist office
• Get curosurf from OB refrigerator and place in small cooler tube to take with you on the medevac
• Make sure FM physician has picked up their OB med kit and supply bag (plus Fetal Fibronectin and GBS swabs etc. for preterm labor patients)

Before you leave

Contact CHAs and give them this list of things to do before your arrival

• Turn up the heat in the clinic and/or clinic room until everyone is sweating (may need to put a portable heater in the room as well).
• Get a table ready in the mom’s room or in an adjacent room with baby blankets, clean towels, chuks, diapers etc.
• Gather portable suction, oxygen tanks and tubing, lamp/s for warming, infant or premie mask (this may not be available at the clinic), self inflating infant size O2 bag, and bulb syringe
• Check to make sure the oxygen, bag with appropriate mask and suction are connected and working
• Call in experienced extra help

Make sure the FM physician that is staying behind in Bethel stays in touch with the village CHA for further management. They should consider giving mom Motrin, Amoxicillin and steroids (Oral Prednisone) in addition to Terbutaline if not already done and preterm delivery is imminent. The FM physician should make sure all the things above are being done in anticipation of a delivery.

Have access to Neonatal Resuscitation Summary, Curosurf Administration Protocol and HF guideline references available, electronically downloaded or a paper copy for reference.

Continued preparation in route to village

• Review the Neonatal Resuscitation Sheet (link here) Determine Medication/Supply/Equipment needed based on estimated gestational age. You can pull a copy out of the neopack to mark up and use for this medevac.
• Determine which medic will be working with you and have him review the drugs and equipment that might be needed for a term/preterm delivery.
• STAY CALM

On arrival at village clinic

• If the baby has not been born and delivery is not imminent…the FM physician will assess the mom’s progression of labor by reviewing contraction record and vaginal exam etc. Occasionally a mom will be transported to Bethel dilated and in reverse trendelenburg—this occurs if the benefit for the baby being closer to a higher level of care outweighs the risks of a potential delivery en route. If the delivery is not immanent and the decision has been made to return to Bethel, it is best to scoop and run. Weather can change and labor may begin again so it is best to head back as quickly as possible in a safe manner.
• If mom is preterm and contracting, make sure the FM physician is giving maximum tocolytics such as Terbutalene, and/or Tordol, Nifedapine etc and antibiotics. If she is < to 34 weeks try to give an IV dose of Betamethasone/Dexamethasone at least one hour before delivery. These can be given in the clinic or en route back to Bethel.
• If the mom cannot be transported to Bethel before she delivers, make sure you are set up for a delivery.
• Check your suction, O2 and ventilation equipment to make sure they are connected and working well. You may also need a meconium aspirator and suction if the infant is > 36 wks
• Make sure your monitors are set up and ready for use
• Review and pull out neonatal resuscitation supplies, meds and equipment based on gestational age with assisting medic. (The second medic will be assisting with the delivery to begin with)
• Get chemical mattress ready with as many external heat sources as possible (lamps work well). Have a polyurethane ‘baby bag’ ready to put on baby for warmth. These are good for even full term infants as keeping a baby warm in a village clinic and on transport can be challenging.
• For high risk infants…IF A BABY IS GOIG TO NEED TO GO TO ANCHOAGE--ACTIVATE A MEDEVAC FROM ANCHORAGE TO BETHEL OR??? SRC ??? OR??? A ramp transfer from one medevac team to another can be considered if the baby is stable.
• Remember NICU docs are available for consultation at 907 212-3614

Village Deliveries

All stable infants >32 weeks Gestational Age

• Put baby on heated chemical mattress and cover with a baby blanket until temperature is stable. Note: Activate mattress just prior to delivery.
• Gently dry infant, remove wet linen, and place diaper under infant.
• Do not block radiant heat (lamp) source while providing care.
• Place skin temp probe over abdomen (preferably on right side over liver). If needed, place small strip of tape over probe to ensure sticking to skin before applying reflective temperature probe cover.
• Monitor axillary temp at 5” and then every 30”
• Obtain patient’s weight (if able) with overhead radiant heat source over baby while weighing.
• Obtain initial glucose and then q 30minutes until stable on D10 maintenance fluids. If blood sugar is < 25 or 25-45 and baby is ill get IV access and give 2 ml/kg D10 IVP, and repeat until BS is > 45. Start maintenance D10 fluids at 80 ml/kg.
• Get iSTAT CBC and blood culture and start antibiotics if there is a concern for sepsis or maternal risk factors
• Consider placing bigger, stable babies in a box to decrease drafts until they can be placed in the isolette.
• Give Erythromycin to eyes & Vitamin K SQ. (Hep B & HBIG can wait until return to hospital)

All Infants < 32 weeks Gestational Age

STEP 1

• Place chemical mattress and polyurethane bag on ‘bed’ prior to delivery. Note: Activate mattress just prior to delivery. Cover the mattress with one nursery baby blanket. Place bag on top of blanket.
• After delivery, place infant directly in plastic bag without drying.
• Temporarily place skin temp probe on upper chest. You may need to gently dry that area. Direct cable to come out top of bag for easy connection to isolette servo when available.
• Ensure plastic bag covers as much of baby as possible (up to neck)-with good seal at top and bottom to prevent draft and evaporative heat loss.
• Keep baby in on chemical mattress and in bag until stabilization transport is completed. ***Note: Remove mattress if chest compressions are needed.
• Cover head with saran wrap. Don’t block radiant heat with care giving activities.
• Begin axillary temperature monitoring: at 5min & then every 30 minutes, If baby is placed in isolette and skin temp probe is accurate and has been correlating with previous axillary temps, it is acceptable to measure skin temperature.

STEP 2: Sat Probe and Respiratory Resuscitation/Stabilization.

• Apply SAT probe. You may be able to place on limb over bag if bag sticks to skin well. If unable, create opening in bag and secure probe through opening.
• If indicated, wipe face gently to prepare for intubation. Apply Duoderm (if available) on upper lip to attach ETT tape to
• Use estimated fetal weight based on gestational age. Do not try to weigh small premies in the village as they get VERY hypothermic.

STEP 3: Keep bag in place for other stabilization procedures and transport

Peripheral Line Placement: • Create opening in bag for access to limb for PIV placement. Secure to IV board.

Consider UVC Placement if no IV access obtained:

• Create opening in plastic.
• Keep bag on infant when preparing sterile field and doing procedure.

If the baby is born and not doing well…

• Ventilate infant with bag-mask.
• If the infant is apneic and requires intubation, prepare the tube, pre-oxygenate, intubate and confirm placement of tube by sound and by end-tidal CO2, etc.
• If a patient is intubated--be prepared to take turns bagging the baby back to Bethel.
• If the infant requires sedation prior to intubation or to maintain intubation, you can use morphine 0.1mg/kg.
• Tape the tube securely in place with benzoin and pre-cut cloth tape (consider duaderm on skin to attach tape to). Neobars are not recommended.
• If patient is < 30 wks please give Curosurf per neonatal resuscitation sheet (link) dose and Curosurf instructions (link) DO NOT give >30 wk infants surfactant without Xray confirmation of RDS or consultation with NICU attending.
• If it is not possible to obtain a good IV then it will be necessary to place a UVC for labs/meds/fluids.
• UVC SETUP AND PLACEMENT (Keep set up sterile!)
  • Get out the kit, a stopcock, and normal saline to flush the catheter and stopcock.
  • -Sterilely prep and drape the umbilicus and drop in UVC line. Use the neonatal resuscitation sheet to determine apprx insertion depth. If baby is in a polyurethane bag…cut hole in bag to place catheter.
  • When umbilical line is placed, use Tegaderm in 2 pieces around umbilicus and secure umbilical bridge to tagaderm. (Tegaderm may not stick to extremely premature skin (<24 wks GA)..
  • Tape in umbilical line with goal post tape and/or use tagaderm over the top of line etc to secure it for transport.
• Bolus only with NS per neonatal resuscitation sheet.
• Use D10 for treatment of hypoglycemia per neonatal resuscitation sheet and as maintenance fluid as needed.
• MAKE SURE TO KEEP THE BABY WARM! Cold babies do very badly.
• Be sure that you or someone you delegate has activated a neonatal Medevac from Anchorage to Bethel as soon as you know that the infant will require transport to Anchorage.
• Remember that NICU docs are available for consultation 907 212-3614

When baby is stable and ready for transport

• Transfer patient to warmed isolette if it is at the clinic.
• Make sure to communicate to hospital staff and they are prepared to receive the infant in Bethel
• If applicable, confirm a neonatal medevac is on its way--it takes a minimum of two hours to get from Anchorage to Bethel
• Transfer the patient as warm and stable as possible to the plane—in the isolette.
• Keep the patient warm on transport
• If patient is intubated use

an anesthesia bag for best bagging control. Take turns bagging to avoid fatigue and ensure good ventilation…and BE CAREFUL NOT TO EXTUBATE A PATIENT it is easy to do…

Pack Supplies For Preterm Village Delivery

Neonatal Bag

Main Compartment

• Chemical mattress x2
• Chux pads
• UVC cath trays x2
• Baby blankets x3
• Umbilical clamps x2
• Cheat sheets
• Deployable chest tube tray
• 8, 10, 12 Fr. chest tubes x2 ea.

Yellow Pouch

• Tegaderms x10
• Neotrode packs x2
• Temp probes x3
• EKG cord
• Temp cord
• Adhesive dots
• Neo BP cuffs—Propaq
• Broselow tape

Green Pouch

• Pedi stethoscopes x2
• Manual Neo BP cuff

Red Pouch

• Stopcocks x2
• 3.5, 5.0 UVC caths x2 ea.
  1. 10, #11 scalpel
• Arm boards x2
• Flexicon Bandages x2
• D10x2
• IV kits x2 with—
  • 18g needle
  • 24g IV cath x2
  • 21, 25g butterfly
  • Purple, amber blood tubes
  • Tegaderm
  • IV start pack
  • Alligator clip
  • T-connector
  • Flush
  • Hep well
  • Heat pack

Blue Pouch

• Bulb syringe L/S
• 10 fr. Delee caths x2
• 5, 8 fr. suction caths x2 ea.
• Nasal aspirator
• 8 fr. inline suction
• 5, 8 fr. feeding tubes x2

Orange Pouch

• Laryngoscope handle
• AA batteries x4
• 00, 0, 1 laryn ,goscope blades
• ETT tape
• Pedi cap
• Meconium aspirator x2
• Benzoine x4
• Neo, infant OPA x2 ea.
• Iodine swabs x2
• Anesthesia bags x2
• Neo, Pedi masks

Medications Available With Medevac Team

Pediatric Meds

• Curosurf
  • Stored in hangar refrigerator. Make sure this is taken on Medevac
• Epinephrine 1:10,000
• Sodium Bicarbonate 4.3%
• Naloxone/Narcan 0.4mg/ml
• D10 (100 or 250 ml bag) for bolus and infusion
• Normal Saline for boluses
• Ampicillin
• Vitamin K SQ
• Erythro eye ointment*
• Phenobarbitol
• Morphine

Preterm Medications For Mom

• Terbutaline
• Tordol
• Magnesium
• Dexamethazone
• Pen G