Pediatric Village Delivery Orientation
- 1 Preparing to go out for a village delivery
- 2 Before you leave
- 3 Continued preparation in route to village
- 4 On arrival at village clinic
- 5 Village Deliveries
- 6 If the baby is born and NOT doing well
- 7 Preparing for Transport from Village Clinic
- 8 Return From Transport
- 9 Neonatal Bag
- 10 Medications Available With Medevac Team
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.
Continued preparation in route to village
- Review the Neonatal Resuscitation Summary. 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, do a vaginal exam and cultures etc. the Lifemed crew will be busy setting up equipment, getting access and administering any meds ordered for mom. Stay out of the way and ask what you can do to help.
- Occasionally a mom will be transported to Bethel dilated and in labor—this only 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 imminent 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, antibiotics and steroids at least one hour before delivery. These can be given in the clinic or en route back to Bethel.
- If mom is going to deliver in the village, make sure you are set up and ready.
- Check your suction, O2 and ventilation equipment to make sure they are connected and working well.
- Make sure your monitors are set up and ready for use
- Review and pull out neonatal intubation and resuscitation supplies plus medications and equipment needed based on gestational age with assisting medic.
- 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.
- Start medevac planning and activation process, as soon as possible, for any known high-risk infant. Consider activation of a medevac from village/SRC to anchorage, ramp transfer in Bethel or SRC or return to Bethel for further stabilization and to meet up with NICU transport crew at the hospital. LifeMed crew can often help with different options for getting baby to Anchorage.
- Call NICU docs for consultation at 907-212-3614 as needed.
Stable infants >32 weeks Gestational Age
- Place chemical mattress on ‘bed’ prior to delivery. Cover the mattress with one thin baby blanket.
- Activate mattress just prior to delivery.
- Consider using polyurethane bag for any baby who is not maintaining temps well
- 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 slow IVP, and repeat until BS is > 45. Start maintenance D10 fluids at 80 ml/kg.
- Give ampicillin if there the baby is preterm or there is a concern for sepsis and/or maternal risk factors
- Consider placing bigger, stable babies in a box to decrease drafts until they can be placed in the transport baby pod.
- Give Erythromycin to eyes & Vitamin K SQ. (Hep B & HBIG can wait until return to hospital)
Infants < 32 weeks Gestational Age
STEP 1: Warming and Initial Assessment
- Place chemical mattress and polyurethane bag on ‘bed’ prior to delivery. Note: Activate mattress just prior to delivery. Cover the mattress with a thin 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 and/or a baby hat. 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.
- Get accucheck glucose
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: Line Placement 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.
- See UV placement instructions below
If the baby is born and NOT doing well
- Ventilate infant with bag-mask or NeoT to keep sats 88-95%, keep warm, start D10 and monitor glucoses and vitals
- Many infants respond well to mask CPAP or High Flow (see HF guideline for Neonatal set up). In most infants greater than 27 weeks, this support may be enough for several hours.
- If the infant is apneic or has increasing respiratory compromise and requires intubation,
- prepare the ET tube and equipment
- if the infant requires sedation prior to intubation or to maintain intubation, use morphine 0.05mg/kg.
- intubate and confirm placement of tube by auscultation and end-tidal CO2.
- 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.
- gently ventilate and increase support as needed using neonatal resuscitation guide as reference
- If a patient is intubated--be prepared to take turns manually ventilating the baby back to Bethel, as the ventilator is not good for use with neonates
- If patient is < 30 wks give Curosurf per neonatal resuscitation guide, but remember there are times when it makes more sense to get an infant back to Bethel before giving curosurf. See Curosurf instructions (link)
- UVC SETUP AND PLACEMENT will be needed if it is not possible to obtain a good IV for labs/meds/fluids.
- Keep set up and procedure sterile!
- If baby is in a polyurethane bag…cut hole in bag to place catheter.
- Get out the UVC kit, a stopcock, and normal saline to flush the catheter and stopcock.
- Sterilely prep and drape the umbilicus and drop UVC line in just far enough to get good blood return. 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.
- UAC line placement is not recommended in the village
- Bolus only with NS per neonatal resuscitation guide.
- Use D10 for treatment of hypoglycemia and maintenance fluid per neonatal resuscitation guide
- MAKE SURE TO KEEP THE BABY WARM! Cold babies do very badly.
- Be sure that you or a 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
Preparing for Transport from Village Clinic
- 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…
Return From Transport
- If baby is not delivered return to the hospital from the airport, with the team or in your car, and remain available for any potential high risk delivery
- If baby was delivered in the village, you may need to accompany the team from the plane to the hospital and get your car later
- For sick infants, continue stabilizing infant at the hospital and make sure NICU medevac team is on the way or already at the hospital for high-risk infants. When NICU team arrives, ask them to allow you to continue to do procedures. Stay involved with the management and care.The baby is the pediatrician’s responsibility until care is transferred to the medevac team as
- For well infants, complete admission orders/med reconciliation, charges and admission H&P. Transfer to FM service if indicated
- For sick infants that require medevac to anchorage, complete admission orders, medication reconciliation, discharge order, charges and admit/transfer note.
Outside Red Pocket
- Anesthesia Bag with infant and neonate masks
- Plastic Cling Wrap
- Intubation Roll
- Pedi-cap x2
- Ped Laryngoscope – Standard Handle
- Laryng Blade Size 00
- Ped Laryng Scope
- Fiberoptic Handle x 1
- Fiber optic Blade Size (0,1)
- 6 fr Malleable Stylet x 2
- 2.0, 2.5, 3.0 Uncuffed ETT
- 2.0,2.5,3.0 Cuffed ETT
- 126.96.36.199,4.0 Small OPA
- 5ml Syringe
- Ballard Neonate Inline Suction
- Meconium Aspirator
- Liquid Adhesive
- Tape Strips
- AA Batteries
- YKHC Broselow Charts
- Sz 6,7,8 Sterile Gloves
- Surgical Gown
- Catheterization Trays x2
- Pneumothroax Kit x2
- Procedure Instructions
- Povidone Swabs x2
- Povidone Pads x 4
- 3 way Stopcock x 1
- 18ga 1 ¼ x 2
- 20ml Syringe x1
Neo Puff Bag
- Neo Puff
- Test Lung
- T-Piece Circuit
- O2 Supply Tubing
- Neo Puff Masks
- 1 ea XS,S,M,L,XL
- 8, 10, 12 fr Chest Tubes x2
- 10 mL syringes x2
- 3-way Stopcock x2
- Suction Y-connector
- 3.5, 5, 8 fr Feeding Tubes x2
- 10 fr Mucus Trap x2
- BBG Nasal Aspirator x2
- 5, 8 fr Suction Catheter x2
- Bulb Syringe x2
- Neo Arm Board x2
- Ped Arm Board x2
- Flexicon x2
- 3-way Stopcock x2
- 3.5 fr UVC x2
- 5.0 fr UVC x2
- 2x IV start kits incl.—
- IV Start Pak
- 24 g IV Cath x2
- Saline Lock
- Lever Lock Cannula
- Infant Heel Warmer
- 10 cc NS Prefill
- Purple Microtainer
- Amber Microtainer
- 3 cc Syringe
Green End Pocket
- Neo/Peds Stethoscope
- Neonate BP Cuffs
- Neonate sizes (1,2,3,4,5) and Infant Size 6
- Neo BP Cord
- Isolation Transport bags x2
- Pacifier x1
- Stocking Bags x2
- Diapers x 2
Outside Blue Pocket
- D10 500 mL x2
Outside Yellow Pocket
- Broselow Tape
Medications Available With Medevac Team
- 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
- Vitamin K SQ
- Erythro eye ointment*
Preterm Medications For Mom
- Pen G