TRANSPORTING NEWBORNS THE S.T.A.B.L.

E WAY

PROGRAM GOAL

Provide a concise guideline of neonatal pre-transport stabilization activities to be employed by community hospital caregivers, in a format that optimizes retention and recall of those activities.

Purpose of the STABLE program

Designed to help health care providers organize care during post-resuscitation/pre-transport stabilization periods.

S - SUGAR
Objectives

Be able to initiate IVF therapy in sick newborns Be able to identify the neonate at risk for developing hypoglycemia and the symptoms of hypoglycemia. Gain an understands of the potential neurologic impact of severe or prolonged hypoglycemia.

S - SUGAR
Objectives

Understand intravenous treatment of hypoglycemia and the post treatment evaluation of hypoglycemia

S - SUGAR
General Guidelines Any baby sick enough to need transport is generally too sick to tolerate oral feedings. Any baby sick enough to need transport will need placement of a peripheral IV or Umbilical catheter prior transport.

S - SUGAR
General Guidelines Sick and stressed neonates are very susceptible to becoming hypoglycemia - Small for gestational age (SGA) - Large for gestational age (LGA) - Infants of Diabetic Mother (IDM) - Premature infants - Infants with perinatal stress: sepsis. shock, asphyxia, hypothermia

RECOMMENDED IVF MANAGEMENT PRIOR TO TRANSPORT D10 Water without electrolyte Run the fluids via an infusion pump at 80 ml/kg/day

Definition of Hypoglycemia

Any plasma glucose level less than 50 mg/dl (2.8 mmol/liter) with symptoms that resolve with glucose treatment ( 1995;Karp,Scardino & Butler)

 the purpose of safety and uniformity the S.T.A.B.L.E program will utilize a target glucose level of 50 mg/dl (2.8 mmol/liter) or higher for infants being transported.

Symptoms of Hypoglycemia

Jitteriness Hypothermia/Temperature instability Lethargy Apathy Hypotonia Apnea Irregular respiration

Symptoms of Hypoglycemia

Poor suck or refusal to eat Vomiting Cyanosis High-pitched or weak cry Seizure

Treatment of Hypoglycemia Blood sugar is less 40 mg/dl

Give an IV bolus of D10 W dose: 2 ml/kg. Recheck blood sugar within 15-30 mins Immediately following the IV bolus, if not done already start an IV infusion of D10 W at 80ml/kg/day

Repeat the IV bolus if the blood sugar is again 40 or less If the blood sugar does not improve and stabilize over 50 after two boluses of glucose. Repeat the glucose bolus and increase the IV to 100120cc/kg/day or change the IV glucose concentration to D12.5W Evaluate the blood sugar frequently q 15-30 min. until stable of >50 on at least two consecutive evaluation.

Treatment Option when the blood sugar is > 40mg/dl but < 50mg/dl
Option 1 Start IVF D10W at 80cc/kg/day Follow-up blood sugar within 30 min. of the low reading and every 30 min.until blood sugar is >50mg/dl on two consecutive evaluation

Option 2 If an IV of D10W is already infusing at 80cc/kg/day and the serum glucose is not rising after 1 hour of IV therapy, increase the IV rate to 100cc/kg/day

T - TEMPERATURE
OBJECTIVES Understand the detrimental effects of cold stress Be able to identify infants at higher risk for becoming hypothermic Understand ways infants lose body heat and be more knowledgeable about protecting the infants against cooling.

T - TEMPERATURE
OBJECTIVES Understands how severely hypothermic infants develop pulmonary vasoconstriction and right to left shunting at the ductus arteriosus and foramen ovale. Understands the process for warming severely hypothermic infants.

T- TEMPERATURE
General Guidelines Keeping babies warm is an instinctual behavior for caregivers Smaller infants are more vulnerable to cold stress.

BODY HEAT IS LOST THROUGH

Conduction Covection Evaporation Radiation

CONDUCTION
Description: heat loss from the baby to a cold surface he is in contact with Causes: infants lies on cold wet linen or a wet diaper Intervention: remove wet linen and or diaper and replace with new dry linen.

CONVECTION
Description: heat loss from the baby to the surrounding air current or environment temperature Causes: air conditioned rooms infants are placed near the air vent Intervention: recommend room temp. 25-28C to obviate heat loss: use incubator:placing the infants away from air draft.

EVAPORATION
Description: heat loss when water turns to vapor Causes: infants skin/head remains wet. Intervention: ensure that baby is dried thoroughly

RADIATION
Description: heat transfer between solid surfaces not in contact with each others. Causes: cold windows or wall Intervention: move infant away from cold windows or wall: use thermal shades over windows: cover the incubator to insulate it from a cold wall or window.

3 Detrimental Effect of Hypothermia

Development of Acidosis Increased Metabolic Rate & Risk of Hypoglycemia Increased Oxygen Consumption

Development of Acidosis

Increase Brown Fat Metabolism Vasoconstriction Anaerobic Metabolism

INCREASE BROWN FAT METABOLISM

COOLING Inc. Brown Fat Utilization Inc. Free Fatty Acid Release Lactic Acidosis

VASOCONSTRICTION

COLLING Norepinephrine release Dec. Oxygen Delivery to the Tissue Hypoxia Dependence on Anaerobic Metabolism Lactic acidosis

ANAEROBIC METABOLISM

COOLING Pulmonary Vasoconstriction Inc. Right to Left Shunts Hypoxemia

Dependence on Anaerobic Metabolism

Lactic Acidosis

Increased Metabolic Rate & Risk of Hypoglycemia

Cooling

Norepinephrine Released

Increased Metabolic Rate

Inc. Oxygen Consumption

Hypoxia

Dependence on Anaerobic Metabolism

Lactic Acidosis

Development of Acidosis

cooling

Inc. Brown Fat utilization

Norepinephrine Released

Increase Metabolic Rate

Free Fatty Acid Released

Pulmonary Vasoconstriction

Peripheral Vasoconstriction

Increased Oxygen Comsantion

Inc. R to L shunts

Dec. O2 delivery to tissue

Hypoxemia

hypoxia

Dependence of aerobic metabolism

Lactic Acidosis

Death

Warming the Severely Hypothermic infants

Increase the Incubator Environment Temperature to 1 to 1.5 C above the body temperature If using radiant warmer, place the skin probe over the liver or abdomen and set the servo control temperature at 36 C. The skin temperature will read 36.6 C before the core temperature is normal. therefore the rectal temp. should be monitored frequently until normal and then axillary temp. can be used.

Monitor the infants HR, BP, RR very closely while rewarming.

What Temperature should be Maintained?

Normal Core Temperature is between 36 C to 37 C Check the temp. every 15-30 min. until within normal range and then at least every hour until the infants is transported.

1. 2. 3.

4.
5.

Maintain Body Temperature with Caution Use of Heat Source: Servo control Radiant warmer Incubator Porta-warmer mattress Heat Lamp

REMEMBER: Preventing heat loss is much easier than overcoming the detrimental effect of cold stress once they have occurred

A ARTIFICIAL BREATHING
PRE-TRANSPORT MONITORING EVELUATION SHOULD INCLUDE; Oxygen saturation (pulse oximeter) Oxygen concentration being delivered Temperature RR and effort HR and Rhythm

A ARTIFICIAL BREATHING
PRE-TRANSPORT MONITORING EVELUATION SHOULD INCLUDE; Blood Pressure Skin perfusion Strength of the pulse in the arms and leg. Chest x-ray Blood sugar screening

A ARTIFICIAL BREATHING
TESTS TO EVALUATE THE CARDIOVASCULAR AND RESPIRATORY SYSTEMS Chest X-ray Blood Gas Hemoglobin and Hematocrit

RESPIRATORY DISTRESS
IN GENERAL: Fast breathing (tachypnia) or labored breathing plus elevated PCO2 usually means there is a PRIMARY LUNG PROBLEM Pneumonia Immature Lungs Aspiration of Amniotic fluids,meconium,blood or stomach fluids

RESPIRATORY DISTRESS
Fast breathing (tachypnia) or labored breathing plus elevated PCO2 usually means there is a

PRIMARY LUNG PROBLEM Lung compromise secondary to diaphragmatic hernia or other chest masses Pneumothorax

RESPIRATORY DISTRESS
Fast Breathing (tachypnia) with a low PCO2(<35) may be secondary to: NON-PULMONARY CAUSES

Heart disease Metabolic Acidosis Brain disorders

Definition of Terms

Hypoxemia below normal oxygenation of the arterial blood Ischemia reduced blood supply to the body or parts of the body, which leads to hypoxia Hypoxia reduced oxygen supply to the tissue, below physiological levels required for normal cell function. Asphyxia a condition in which there is significantly reduced oxygen supply to the tissue with build-up of carbon dioxide and lactic acid.

Hypoxemia Detrimental Effects

Hypoxemia And Ischemia Hypoxia Asphyxia Cell and Organ Damage Survival w/ damage? Death?

Other Complication of Hypoxemia

Severe Hypoxemia Blood Oxygen and pH are low

Constriction of Lung Blood Vessels.

Inc. Right to Left shunts Hypoxia and Acidosis Persist PPHN

RESPIRATORY SYSTEM WARNING SIGNS

RR > 60 breaths /min with inc. work of breathing (moderate to severe retraction, grunting, nasal flaring) Increasing oxygen concentration To maintain oxygen saturation less than 90%. Rapidly increasing oxygen concentration to maintain O2 saturation > 90%.

RESPIRATORY SYSTEM WARNING SIGNS

Marginal oxygen saturation(<90) or > 50% oxygen. Note this may present without significant signs of respiratory compromise in infants with cyanotic heart disease. RR >60 plus very labored breathing (severe sternal, subcostal, intercostal, and or suprasternal retraction plus may have grunting and or nasal flaring) May have periods of periodic breathing or apnea Apnea or Gasping (an ominous, precardiac arrest)

EVALUATE RESPIRATORY DISTRESS

1.
2. 3.

4.

RETRACTION None Mild (intercostal) Moderate (intercostal and substernal) Severe (deep substernal, plus may have intercostal and suprasternal retraction)

EVALUATE RESPIRATORY DISTRESS

1.
2.

3.

COLOR Pink Blue extremities but centrally pink Centrally blue, gray, or very pale.

EVALUATE RESPIRATORY DISTRESS

1.

2.

3.

PERFUSION Rapid (<3 seconds) capillary filling time over trunk and legs Slow capillary filling time (> 3 seconds) over trunk and legs. May have mottling of the skin Slow capillary filling time plus pale skin color and cool extremities. May have significant skin mottling.

EVALUATE RESPIRATORY DISTRESS

1.
2.

3.

4.

5.

OXYGEN NEED None and O2 saturation > 90 Less than 50% oxygen to keep O2 saturation >90% or arterial PO2 > 50 Greater than 50% oxygen to keep O2 saturation >90% or arterial PO2 >50 >80% oxygen to keep O2 saturation >90% or arterial PO2 >50 100% oxygen fails to keep O2 Saturation > 90% or PO2 above 50.

BLOOD GAS EVALUATION

Normal Values Arterial pH <48h 7.30-7.40 pH <48h 7.35-7.45 pCO2 35-45 pO2 50-80 HCO3 19-22 Base -2 (+2) O2 Sat.

Capillary 7.30-7.40 7.35-7.45 35-50 35-45 19-22 -2 (+2) 90-95%

Intubation and Positive Pressure Ventilation Should Be Strongly Considered IF; Youre unable to ventilate and or oxygenate adequately with bag/mask ventilation When prolonged bad and mask ventilation is required The infants ha s a Diaphragmatic Hernia The PCO2 is >55, especially if the pH is <7.25

Intubation and Positive Pressure Ventilation Should Be Strongly Considered IF; The infants is breathing with significant difficulty. The Infants has periods of Apnea interspersed with hard breathing efforts or the infants has recurrent severe apneic and bradycardic episodes.

ENDOTRACHEAL TUBE SIZE

ETT size Weight Age by wk. 2.5 < 1000 below 28 3.0 1000-2000 28-34 wk 3.5 2000-3000 34-38 wk 3.5-4.0 Above 3000 Above 38

ENDOTRACHEAL TUBE INSERTION DEPTH

Rule for insertion death at the LIP (LIP to TIP: Add 6 to the infants weight in kg.

Weight Insertion depth (cm) < 1000 g 6 cm 1000-2000 g 7 cm 2000-3000 g 8 cm 3000-4000 g 9 cm Over 4000 g 10 cm

Complications of the Procedure

1.

2.

Hypoxia - taking too long to intubate - Shorten intubation Bradycardia/Apnea - hypoxia (vagal response due to the larynscope blade, ET tube, suction catheter, stimulating the posterior pharynx . - Bag mask, bag ET tube ventilation with O2

Complications of the Procedure

3. Pneumothorax - Overventilation of one lung due to displacement of the tube in a main bronchus (Rt) - Proper positioning of ET tube and appropriate ventilation pressure.

Complications of the Procedure

4. Contusion or laceration of tongue, gums, pharynx, epiglottis, trachea, vocal cord, or esophagus -Rough handling of laryngoscope or ET tube and Laryngoscope blade is too long or too short - Additional practice/skill and more appropriately sized equipment.

Complications of the Procedure

5. Perforation of trachea or esophagus, - Insertion of tube or stylet is too vigorous or stylet protudes beyond end of tube. - Proper placement and curvature of stylet and Gentler handling.

Complications of the Procedure

6. Infection - Introduction of organisms via equipment of hands. - More careful attention to clean/sterile technique.

Congenital Diaphragmatic Hernia

Signs and Symptoms Respiratory distress characterized by; 1. Cyanosis 2. Scaphoid abdomen 3. Decreased or absent of breath sound on the affected side. 4. Heart sounds that are heard best on the opposite side.

Congenital Diaphragmatic Hernia

PNEUMOTHORAX
Signs and Symptoms; 1. Apnea 2. Cyanosis 3. Increased work of breathing 4. Tachypnia 5. Grunting 6. Nasal flaring 7. Retraction 8. Hypoxemia 9. Hypercarbia 10. Development of respiratory or Metabolic Acidosis.

PNEUMOTHORAX

PNEUMOTHORAX
Other signs include 1. Bradycardia 2. Hypotension 3. Chest asymmetry 4. Shift in the point of maximal heart impulse 5. Difficulty feeling the femoral pulses 6. Mottled appearance.

B - BLOOD PRESSURE
Definition Shock Inadequate vital organ perfusion and oxygen delivery (Corneli, HM., 1993) An acute, complex state of circulatory dysfunction resulting in insufficient oxygen and nutrient delivery to satisfy tissue requirement (Kourembanas, S., 1998)

The Three Main Causes of SHOCK

1.

HYPOVOLEMIA Most common type of shock in newborn Acute blood lose as that seen in placenta previa and abruption may present with hypotension Poor cardiac output. Peripheral vasoconstriction, cyanosis and acidosis Fluid losses because of dehydration or effusion.

The Three Main Causes of SHOCK

CARDIOGENIC SHOCK This is a state in which the heart muscle functions very poor. Some causes of Cardiogenic Shock 1) Intrapartum asphyxia 2) Hypoxia and /or Acidosis 3) Bacterial or Viral infection 4) Severe hypoglycemia 5) Arrhythmias ( if prolonged) 6) Congenital heart defects

The Three Main Causes of SHOCK

3. SEPTIC OR DISTRIBUTIVE SHOCK Blood vessels tend to dilate, which leads to low BP There will be loss of vascular integrity which allow for leakage of fluids out of the blood vessels and into the tissue space.

Evaluating The Infants for Shock

1.

2.
3. 4. 5.

Poor Peripheral Perfusion (signs of vasoconstriction and poor cardiac output) > 3 seconds capillary filing time Pallor Mottling Cool skin Decreased peripheral pulses

Evaluating The Infants for Shock

1.

2.

3.

Heart Rate Tachycardia (sustained HR >180 bpm at rest) Bradycardia (<100 bpm) with very poor perfusion Evaluate for the presence or absence of heart murmurs

Evaluating The Infants for Shock

1.

2. 3. 4.

Respiratory Effort Increased work of breathing/retraction Tachypnia Irregular respirations Gasping

Evaluating The Infants for Shock

1.

Blood Pressure Normal or Low - blood vessels may be constricting and blood may be shunting away from non-vital organs in order to preserve central blood pressure or blood pressure is normal but the body still looks like shock is present.

Evaluating The Infants for Shock

Blood Gas Evaluate for the presence of metabolic acidosis and hypoxemia pH <7.30 is abnormal pH <7.25 is concerning especially if in combination with poor perfusion, tachycardia and or low BP. pH < 7.20 is very concerning pH < 7.15 indicates the infants is in severe crisis.

Treatment of Shock
One Main Goal: To Reverse Asphyxia - a condition in which there is significantly reduced oxygen supply to the tissue with building up of carbon dioxide and lactic acidosis.

Treatment Of Shock
This is accomplished by: Improving CO Increases tissue perfusion and oxygenation Decreases anaerobic metabolism Increasing the hemoglobin and hematocrit

HYPOVOLEMIC SHOCK

1.

Treatment involves improving the circulating blood. This can be accomplished by using: IF THERE IS NO ANEMIA Normal Saline Solution or Ringers Lactate -10 cc/kg over 15-30 min. IV, UVC, Intraosseous - With severe shock, volume boluses may need to repeated two or three times.

HYPOVOLEMIC SHOCK
2. IF THERE IS ANEMIA SECONDARY TO HEMORRHAGE Normal Saline to begin volume resuscitation while awaiting: Packed RBC or Whole blood

CARDIOGENIC SHOCK
Evaluate the Infants for 1. Tachycardia 2. Bradycardia 3. Hypotension 4. Oliguria 5. Hypoxemia 6. Acidosis 7. hypoglycemia

CARDIOGENIC SHOCK

VOLUME EXPANSION - to improve the circulating blood volume. SODIUM BICARBONATE 4.2% Solution (0.5 meq/ml) - 1-2 meq/kg/dose (equals 2 to 4 ml/kg/dose) over 30 to 60 min IV. DOPAMINE 5-20 mcg/kg/min (IV continuous infusion drip via IV pump) - At higher dose , Vasoconstriction result with vasopressors like dopamine

DOPAMINE DOSE & EFFECT

Dose
1-3 mcg /kg/min

Receptors
Dopaminergic

Effects
Renal Mesenteric Cerebral vascular dilatation Inc. CO and BP

5-10 mcg /kg/min 10-20 mcg /kg/min HR

Beta-adrenergic

Alpha-adrenergic

Inc. vascular resistance, BP,

Dopamine Preparation
Computation; 6 x wt.in kg x Desired dose/ Desired amount of fluid ml/hr = mg of dopamine per 100 ml of solution

Rules for Dopamine Mixing

Use 10 (mcg/kg/min) as the desired dose. Use 2 ml/hour as the denominator. - will allow you to decrease or increase the dose with ease without having to remix the solution each time a change in dose is desired. Mix Dopamine In D10W IV solution

DOPAMINE INFUSION RATE

DOPAMINE mcg/kg/min 5 7.5 10 12.5 15 20

IV rate ml/hr 1 1.5 2 2.5 3 4

Rules for Dopamine Infusion

Dopamine should follow boluses of NS or Ringer solution Start at 5 mcg/kg/min and increase by 2.5 mcg/kg/min increments until the desired effect is seen. Never give through an Umbilical Artery Catheter or any other arterial site.

Rules for Dopamine Infusion

Dopamine should be given through a separate peripheral IV or an Umbilical vein if the catheter position has been confirmed by CXR and the tip is appropriately located above the liver at the inferior vena cava/ right atrial junction. Never push Dopamine or lines containing Dopamine Always infuse using an infusion pump.

Rules for Dopamine Infusion

Monitor the infusion site very carefully for extravasations and change infusion sites if the IV should infiltrate. Monitor the blood pressure and heart rate every 1-2 min. for 15 min. then every 2-5 min.depending upon response to the medication. If an infants is failing to respond to a dose of 20 mcg/kg/min then increasing the dose further is usually not helpful.

SEPTIC SHOCK

Usually the treatment involves a combination of hypovolemic and cardiogenic shock therapies. Require two or three 10 ml/kg fluid boluses of NS and continuous drip infusion of Dopamine prior transport.

L LAB WORK
NEONATAL INFECTION Evaluation and treatment of suspected sepsis should be one of your top priorities during pretransport period.

L LAB WORK
Risk Factors for Infection
Some risk factor for Neonatal Infection 1. Premature rupture of membrane 2. Premature delivery 3. Recent maternal infection or illness 4. Rupture of membrane longer than 18 hours 5. Instrumentation delivery or in the nursery

L LAB W ORK
CLINICAL SIGN OF SEPSIS Respiratory distress - tachypnia, retraction, grunting nasal flaring and apnea. - development of an oxygen requirement. Abnormal Skin Perfusion - Mottling, pale color, gray color, delayed capillary refill time.

L LAB W ORK
CLINICAL SIGN OF SEPSIS Temperature instability - hypothermia and rarely hyperthermia. Feeding intolerance - Vomiting, abdominal distension, poor feeding pattern. Abnormal HR and BP - tachycardia, bradycardia, hypotension Abnormal Neurologic status - Lethargy, hypotonia, seizure

L LAB W ORK
Neonatal Group B Streptococcal Infection When transmitted to the fetus may cause significant illness characterized by: 1. Meningitis 2. Sepsis 3. Pneumonia Estimated that between 10% and 30% of women are vaginal and rectal GBS carriers. Incidence of Neonatal GBS sepsis in the U.S. 1.8 cases /1000 live births or 7,600 episode per year

L LAB W ORK

The 4 Bs Blood Count Blood Culture Blood Sugar Blood Gas

L LAB W ORK
CBC INTERPRETATION Neonates have an immature immune system which place them at higher risk for infection Neutrophils battle bacterial infection and may become depleted in sepsis

L LAB W ORK
CBC INTERPRETATION Proerythroblast = Erythrocyte (RBC) Megakaryoblast = Platelet Basophilic myelocyte = Basophil Myeloblast Neutrophil myelocytes metamyelocytes Bands = Mature Neutrophil Eosinophilic myelocytes = Eosinophil Lymphoblast = Lymphocytes Monoblast = Monocytes

Calculating The ANC

Example ; CBC result 6 hr old neonate. WBC = 15,000 (15 x10/Ul) Segmented Neutrophil (SEG) 35% Band Neutrophil (bands) = 15% Metamyelocyted (METAS) = 3% 1. SEG + BAND + METAS = 53% 2. 15,000 X 0.53 = 7950 3. ANC = 7950

Why is it Important to Calculate the ANC

Screening tool for caregivers for sepsis. Infants who fall below the norm for their postnatal age, because this indicate a depletion of the total number of neutrophilic WBC the infants has fighting for infection. Exhaustion of the neutrophil storage pool in the bone marrow is very serious for the newborn Infants who deplete their WBC reserves while fighting infection are at higher risk of dying from sepsis.

Calculating The I/T Ratio

Example SEGS = 35% BANDS = 15% METAS = 3% 1) BANS + METAS = 18% 2) SEGS + BANS + METAS = 53% 3) 18% divided by 53% = 0.34 4) The I/T Ratio is 0.34 I/T ratio > 0.25 may indicate sepsis I/T ratio > 0.8 is correlated with higher risk of death from sepsis

PLATELET COUNT
Platelet Count Normal Value VLBW (<1500 gms) 275,000 +/60,000 Preterm (<2500 gms) 290,000 +/70,000 Term 310,000 +/68,000

Platelet Count

In the Presence of neonatal sepsis the platelet count may be low Platelet count between 100,000 to 150,000 should be carefully evaluated especially if there has been a downward trend from previous sample Platelet count less than 100,000 are definitely abnormal and should be follow up again within 12-24 hours Platelet count less than 25,000 are dangerous low. Repeat the test and confirm accuracy.

Antibiotic Therapy

Ampicillin 50-100 mg/kg/dose q 12 hours IV Gentamicin 2.5 mg/kg/dose q 12 to 24 hours IV over 30 min. (interval depends upon gestational age and renal function)

E EMOTIONAL SUPPORT
Objective: Participant will understand: Crisis families expereince when an infants requires Neonatal intensive care Ways healthcare providers can support parents of sick infants Facilitating parenting in NICU

E EMOTIONAL SUPPORT

This is major crisis and shock for families Parental emotions may include - guilt - powerlessness - anger - fear - disbelief - blame - sense of failure - depression

E EMOTIONAL SUPPORT
Initial Stabilization Period Before transport facilitate maternal visit with infants Congratulate parents on birth of child Call infants by name if one has been given

E EMOTIONAL SUPPORT
Initial Stabilization Periods Refer to infants by correct gender Use terms your son or your daugther to support identification as parents Take picture of infants Identify support people

E EMOTIONAL SUPPORT
When the Transport Team Arrives Listen to explanation regarding infants condition and likely medical treatment Observed parents reaction and discuss infants and parents situation to enable specific intervention and consultation.

E EMOTIONAL SUPPORT
When the Transport Team Arrives Validate parents understanding of explanation - commonly parents have difficulty remembering what was explained - expect to repeat explanation

E EMOTIONAL SUPPORT
When the Transport Team Arrives Validate parents understanding of explanation - provide written maternal and illustrations - be aware of reading limitations - recommend parents write down or ask question as they arise

E EMOTIONAL SUPPORT
When the Transport Team Arrives Provide complete medical records to transport team - Maternal perinatal, labor and delivery, laboratory, medication - Infants orders, nurses and respiratory theraphy notes, physian notes, laboratory,

E EMOTIONAL SUPPORT
When the Transport Team Arrives Provide complete medical records to transport team - Infants orders, nurses and respiratory theraphy notes, physician notes, laboratory, medication - copy of radiographs (x-ray)

E EMOTIONAL SUPPORT
When the Transport Team Arrives Encourages and initate pumping of breast if mother wishes to breast feed If parents identify communication issues offer to call receiving hospital and facilitate communication with nursing and medical staff.

E EMOTIONAL SUPPORT
In the NICU Recognize gender and culture difference with coping, illness experience, stress Help with adjustment to altered way of parenting- but parenting all the same:

E EMOTIONAL SUPPORT
In the NICU Help with adjustment to altered way of parenting- but parenting all the same: - congratulate parents on birth of child - involve parents from beginning -be supportive and nonjudgmental

E EMOTIONAL SUPPORT
In the NICU Explain infants condition in simple accurate, honest terms Locate non-family member translator if language ba rrier Encourage parents to : -interact with their infants - talk with each other about infants situation, feelings