Introduction • The organization of a good quality special care neonatal unit (SCNU) is

essential for reducing the neonatal mortality and improving the quality of life among the
survivors. • Govt. of India has launched an initiative to establish SCNUs at district hospitals
to provide: • Care at birth including resuscitation of asphyxiated newborns. • Management of
sick newborns. • Referral and transport services for babies needing mechanical ventilation
and major surgical interventions. • Post-natal care and immunization services • Follow-up of
high risk newborns.

LEVELS OR GRADES OF NEONATAL CARE •Level I •Level II •Level III

LEVELS OF NEONATAL CARE LEVEL I CARE •The minimal care For care of newborns
more than 1800 grams or G.A. ≥ 34 weeks. • The care consists of basic care at birth,
provision of warmth, maintaining asepsis and promotion of breastfeeding. • This type of care
can be given at home, subcenter and primary health centre.•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 includes
care of delivery, provision of the warmth, maintenance of asepsis, and promotion of breast
feeding.

LEVELS OF NEONATAL CARE LEVEL II CARE •This care includes requirement for
resuscitation, maintenance of thermo-neutral temperature, intravenous infusion, gavage
feeding phototherapy and exchange transfusion. Neonates weighing 1200-1800 grams or
G.A. between 30–34 weeks are categorized under level II care and are looked after by trained
nurses and pediatricians. • The equipment and facilities used for this level of care include
equipment for resuscitation, maintenance of thermoneutral environment, intravenous
infusion, gavage feeding, phototherapy and exchange blood transfusion. • This type of care
can be given at first referral units, district hospitals, teaching institutions and nursing
homes.•10-15 percent of the newborn require this care • This care s is anticipated for the
infants weighing in between 1500 & 1800 gm or having gestational age maturity of 32 to 36
weeks.

LEVELS OF NEONATAL CARE LEVEL III CARE Neonates weighing less than 1200
grams or having gestational maturity of less than 30 weeks are categorized under level III
care. • The care is provided at apex institutions and regional perinatal centres equipped with
centralized oxygen and suction facilities, servo-controlled incubators, vital signs monitors,
transcutaneous monitors, ventilators, infusion pumps etc. • This type of care is provided by
skilled nurses and neonatologists.•This care includes life saving support system like
ventilator and best suited special intensive neonatal care. •Three to five percent of newborn
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.

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:

1. PHYSICAL FACILITIES
2. NURSERY DESIGN
3. PERSONNEL
4. EQUIPMENTS
5. LABORATORY FACILITIES
6. PROCEDURE MANUAL
7. TRANSPORT OF SICK INFANTS
8. COOPERATION BETWEEN THE OBSTETRICIAN AND NEONATOLOGIST

1.PHYSICAL FACILITIES:

 Location
 Space
 Floor plan
 Lighting
 Environmental temperature and humidity
 Handling and social contacts
  Communication system
 Acoustic characteristics
 Ventilation
 Electrical outlets

LOCATION:

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

• Adequate sunlight for illumination

• Fair degree of ventilation for fresh air

• The presence of an elevator in close proximity is desirable for transport of out born babies.

SPACE:

The size of the unit is related to the expected population intended to be served.

• In a maternity unit having 2000 deliveries/year, facilities for special care of 6- 8 high risk
infants should be available.

• Each infant should be provided with a minimum area of a 100 sq ft (10 meter square).

• Space for promotion of breast feeding 500-600 Grss square feet per bed.

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

LIGHTING

The nursery must be well illuminated and painted white or slightly off white to permit prompt
and early detection of jaundice and cyanosis.
It is best achieved by cool white fluorescent tubes or LED (light-emitting diodes) to provide
at least 100 foot-candle, shadow free illumination at the infant s level.

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 In places
where electrical failure is frequent and prolonged, the electrical system of the nursery
complex must be attached to a generator.

Exposure of preterm babies to strong light has been incriminated as a risk factor for the
development of retinopathy of prematurity

TEMPERATURE:

The temperature of the nursery complex must be maintained between 26 – 28 ͦC (78.8 -

82.4°F) in order to minimize effects of thermal stress on the babies.

This is best achieved by centralized air conditioning having temperature control knobs in the
nursery.

The air movement should be so designed that draught is minimized. In places where air
conditioning is not feasible, room temperature can be reasonably well maintained in winter
by use of radiant heaters and hot air blowers.

Portable radiant heater, infrared lamp or bakery bulb can be used to provide additional source
of heat to an individual infant.

The external windows of nursery should be glazed to minimize heat gain and heat loss and
baby beds should be located at least 2 feet (0.6 meter) away from the wall or window.

HUMIDITY

• In most parts of India, relative humidity averages above 50%, which is quite satisfactory for
routine needs of newborn babies.

• Humidity level can be raised for preterm babies nursed in an incubator.

High and effective humidity level is useful to reduce insensible water loss but is associated
with increased risk of nosocomial infection.

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

VENTILATION:

Effective air ventilation of nursery is essential to reduce nosocomial infections. The most
satisfactory ventilation is achieved with laminar air flow system which is rather expensive.

When centralized airconditioning is used, minimum of 12 changes of room air per hour are
recommended.

There should be no draughts of air on and near the newborn beds.

The air-conditioning ducts must be provided with millipore filters (0.5 u) to restrict the
passage of microbes. A simple method to achieve satisfactory ventilation consists of
provision of exhaust fan in a reverse direction near the ceiling for input of fresh
uncontaminated air and fixation of another exhaust fan in the conventional manner near the
floor for air exit.

A constant positive air pressure should be maintained in the nursery so that contaminated air
from the corridors does not gain access into the nursery.

ACOUSTIC CHARACTERISTICS

 The ventilation system, incubators, air compressors, suction pumps and many other
devices used in the nursery produce noise.
 Sound intensity in the nursery should not exceed 75 dB to protect hearing of nursery
personnel and infants.
 Excessive noise may lead to hearing loss, physiological and behavioral disturbances,
such as sleep disturbances, startles and crying episodes, hypoxia, tachycardia and
increased intracranial pressure.
 It is desirable to have effective soundproofing of ceilings, walls, doors and floor when
a new nursery is designed.
 Telephone rings and equipment alarms should be replaced by blinking lights.
 The ventilation system, incubators, air compressors, suction pumps and many other
devices used in the nursery produce noise
ELECTRICAL OUTLETS
  Each infant must be provided with at least eight electrical outlets, 4 should be 5
amperes and another 4 of 15 amperes.
 The use of adapters and extension boards should be discouraged. The electrical
equipment used in the nursery must be checked at least once a month for leakage of
current.
 Special fittings with safety devices should be installed.
 The unit should have round-the clock uninterrupted servo-stabilized power supply.
 There should be round-the-clock power back-up including provision of UPS system
for the sensitive equipments

2. NURSERY DESIGN: The unit design may be in a square space or a single corridor based
rectangular unit. A split unit (on either side of the hospital corridor) should be avoided, for
prevention of infections.

The areas in nursery includes

 Examination area
 Mother area
 Baby care area
 Nurses’ station
 Hand washing and gowning area
 Preparation of iv fluids
 Clean utility area and soiled ….
 Staff room
 Growing nursery

Examination area

A small comfortable room with examination table, comfortable seating, sufficient light, and
warmth is needed for assessment of baby before admission to the nursery.

Mother area
The room should be provided with comfortable seating and privacy to the mother to
breastfeed and express the breast milk with the help of a lactation nurse.

Baby care area

The unit should be provided with areas and rooms for inborn or intramural babies, step down
nursery, out born or extramural babies, examination area, mother’s area for breastfeeding and
expression of breast milk, nurses station and charting area. The obviously infected infants
with open sepsis (especially those with diarrhea and abscesses) should be isolated in a septic
nursery, which should be located away from the SCNU and manned by different nursing and
resident staff.

Nurses station

• Nursing station and charting area for nurses and residents should be located in a central area
from where all the babies can be observed. Newborn charts, hospital forms, computer
terminals, telephone lines should be located in this area. It is preferable to use electronic
medical recording of clinical notes and retrieval of laboratory reports

hand-washing and gowning room:

Handwashing and gowning facility should be located at the entrance. It should be provided
with abundant space with self closing doors. • A positive air pressure should be maintained in
the SCNU so that corridor air does not enter the SCNU. • Street shoes are changed with
nursery slippers, followed by handwashing and gowning. • Hand free elbow-operated
handwashing sink with liquid soap dispenser is recommended. The unit should be provided
with 24-hour uninterrupted water supply by having dedicated over head tank with a capacity
of 1000 - 2000 litres. Handwashing sinks should be provided within 20 feet (6 meters) of
every newborn bed. • The sink should be large and deep (24” wide ×16” front-back ×10”
deep). • Antiseptic sanitizing solution (sterillium) can be used for disinfection of hands in-
between the babies.

Preparation of intravenous fluids

• A separate area should be provided with a laminar flow system for preparation of
intravenous fluids, parenteral nutritional formulations, enteral feeds and medications.

Clean utility and soiled utility holding rooms

• There should be enough space for stocking clean utility items and sterile disposables, and
for disposal of dirty linen and contaminated disposables.

• The ventilation system in the soiled utility or holding room should be engineered to have
negative air pressure with all air being exhausted to the outside.

• The soiled utility room should be so located that it enables removal of soiled material
without passing through the baby care area.

Staff rooms

• Space should be provided within the unit to meet the professional, personal and
administrative needs of resident staff on duty.

• A comfortable room with intercom, telephone and computer terminal and WC facilities is
mandatory.

• Nurse’s Change room is required for changing from formal street clothes to dress stipulated
by the NICU.

Growing nursery

• A separad-0te area for transitional care of high-risk babies by their mothers before they are
discharged from the hospital.

• The entry of visitors to this area should be restricted and it should be kept adequately warm.

• Facilities for vitals monitoring and weighing the babies should be available in the
transitional care room (TCR) or growing nursery (GN).

• The growing nursery is used with advantage for educating the mothers in child craft
activities and promoting the practice of exclusive breastfeeding.

3.Personnels

1. Doctors
2. Intensivist
3. Obstetrician
4. Staffnurses
5. Neonatologist
 6. Surgeon
7. Respiratory therapist / physiotherapist
8. Laboratory technician
9. Public health nurse or social worker
10. Biomedical engineer
11. Chaplin
12. Clerk.
13. Lab technician
14. Biomedical technician
15. Pathologist

STAFF • 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 handon-
training in an intensive care neonatal unit.

5. Equipments:

The fundamental needs of the unit are availability of adequate space, freedom from
congestion and presence of a sufficient number of adequately trained nurses Acquisition of
new equipment does not necessarily ensure better services and outcome. • Machines cannot
replace men. The best monitors with us are dedicated nurses and resident doctors involved in
the care of newborn babies with their observational skills sharpened by experience.
Therefore, they need continued in service training.
Emergency tray should be available in each infant care room of SCNU containing Ambu bag
and mask, infant laryngoscope, tracheal tubes of different sizes, sterile suction catheters, oral
mucus suction traps, and emergency drugs. • Bag and Mask Resuscitator -Self-inflating bag
of 250 / 500 mL capacity is ideal for resuscitation of a newborn baby. • An oxygen reservoir
in the form of a corrugated tube or reservoir bag, helps to increase the oxygen concentration
to 90 to 100%.

Oxygen and suction facility • Catheter syringes and needles • Feeding equipments- glass and
stainless steel bowels of adequate size • Weighing machine • Pulse Oximeter • Infusion or
syringe pump • Blood Pressure Monitors

 RADIANT WARMER
 BABY WEIGHING MACHINBE
 THERMOMETER
 DEFIB
 WHEEL CHAIR
 AMBU BAG
 DIGITAL MONITOR
 LAMINAR FLOW
 OXYGEN FLOW METER
 SUCTION APPARATUS
 HUMIDIFIES
 NEBULIZER
 PHOTOTHERAPY
 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

6. Laboratory facilities (COT-SIDE)

• Satisfactory facilities for routine radiological examination should be available in the nursery
round-the clock.
• A side laboratory for routine analysis of blood, urine, glucose, bilirubin, hematocrit should
be available.

• Facilities for analysis of serum sodium, potassium, calcium and total serum proteins, and
albumin should be at hand.

• The collection of venous blood is often difficult and hazardous in sick preterm babies.
These babies often require frequent biochemical estimation.

• Thus a microchemical laboratory which can carry out investigations on very small samples
of blood obtained in heparinized capillary tubes or microcentrifuge tubes from heel puncture,
should be considered as an essential facility for SCNU.

7. PROCEDURE MANUAL

MODULE CONTENTS

The module includes following elements:

Essential modules should be available such as:

 INTRAMUSCULAR INJECTION
 ADMINISTRATION OF COMMONLY USED MEDICATIONS
 INTRAVENOUS CANNULATION
 OXYGEN THERAPY
 INSERTION OF OROGASTRIC TUBE & ORO-GASTRIC TUBE FEEDING
 EXPRESSION OF BREASTMILK
 TEMPERATURE RECORDING
 WEIGHT RECORDING ON A DIGITAL MACHINE
 OROPHARYNGEAL SUCTION
 GLUCOSE MONITORING BY HEEL-PRICK
 DEVELOPMENTAL SUPPORTIVE CARE AND PAIN MANAGEMENT IN
NEWBORNS
 NURSING CARE OF BABY ON CPAP
 SCREENING FOR RETINOPATHY OF PREMATURITY
 EMERGENCY TRIAGE ASSESSMENT AND TREATMENT
 TRANSPORT OF A SICK BABY
 TRANSPORT OF SICK INFANTS
Newborn transport is used to move premature and other sick infants from hospitals without
specialist, intensive care facilities require for optimal care of the baby to hospitals with
neonatal intensive care and other specialist services.

TRANSFER

• Transfer can be within the hospital; to ICU

• Transfer can be to other hospital

Neonatal transfer types

• Emergency: unplanned

• Elective : planned and informed

transfer procedure

• 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.

• Themocele (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.

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

principles of safe transport

• Sugar

• Temperatur.e

• Airway

• Blood pressure

• Lab work

• Emotional support

• Stable vitals

• Arterial circulatory support

• Family support

• Environment

• Respiratory support

• Temperature
• Oxygenation (airway and breathing)

• Perfusion

COOPERATION BETWEEN THE OBSTETRICIAN AND NEONATOLOGIST

•Antenatal care and fetal diagnosis

•Perinatal hypoxia

•Promotion of feeding with human milk

•Supervised care of low birth weight

MANAGEMENT OF NURSING CARE

1. Assessment 2. Monitoring physiological data

3. Safety measures

4. Respiratory support

5. Thermoregulation

6. Protection from infection

7. Hydration

8. Nutrition

9. Feeding resistance

10. Skin care

11. Administration of medication

12. Developmental outcome

13. Facilitating parent-infant relationship

14. Discharge planning and home care

15. Neonatal loss

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.