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Submitted To:
Mrs. Martha Raut
Mrs. Monika Bagchi
Asst Prof
2 year MSc N
Submitted On: 17/02/2016

Newborn intensive care approach developed from the concept that a more
intensive approach to neonates who require special care would result in a
significant decrease in neonatal mortality and morbidity. A neonatal intensive
care unit (NICU) is an intensive care unit specializing in the care of ill or
premature newborn infants. The first official ICU for neonates was established
in 1961 at Vanderbilt University Mildred Stahlman, officially termed a NICU
when Stahlman used a ventilator off-label for a baby with breathing difficulties,
for the first time ever in the world.
It is very specialized unit where critically ill neonates are cared to reduce the
neonatal morbidity and mortality.

Low birth weight

Large babies

Birth asphyxia(APGAR score less than or equal to 6)

Me conium aspiration syndrome

Severe jaundice

Infants of diabetic mother

Neonatal sepsis/meningitis

Neonatal convulsions

Severe congenital malformation

O2 therapy/parenteral nutrition

Immediately after surgery

Cardio respiratory monitoring

Exchange blood transfusion

PROM/foul smelling liquor

Mother of Hepatitis B carrier

Injured neonate.


The goals of neonatal intensive care unit are

To improve the condition of the critically ill neonates keeping in mind

the survival of neonate so as to reduce the neonatal mortality and

To provide continuing in-service training to medicine and nursing

personnel in the care of newborn.

To maintain the function of the pulmonary ,cardiovascular, renal and

nervous system

To monitor the heart rate, body temperature, blood pressure,central

venous pressure and blood by non invasive techniques.

To measure the oxygen concentration of the blood by oxygen analysers

To check/observe alarms systems signal ,to find out the changes beyond
certain fixed limits sets on the monitors.

To administer precise amounts of fluids and minute quantities of drugs

through I.V infusion pumps.



Evaluation and postnatal care of healthy newborn infants;

Care for infants with corrected gestational age greater than 34 weeks or
weight greater than 1800 g who have mild illness expected to resolve

quickly or who are convalescing after intensive care

Ability to initiate and maintain intravenous access and medications

Nasal oxygen with oxygen saturation monitoring (e.g., for infants with
chronic lung disease needing long-term oxygen and monitoring

Normal new born care


Care of infants with a corrected gestational age of 32 weeks or greater or

a weight of 1500 g or greater who are moderately ill with problems

expected to resolve quickly or who are convalescing after intensive care

Peripheral intravenous infusions and possibly parenteral nutrition for a

limited duration
Resuscitation and stabilization of ill infants before transfer to an

appropriate care facility

Mechanical ventilation for brief durations (less than 24 h) or continuous
positive airway pressure. Intravenous infusion, total parenteral nutrition,

and possibly the use of umbilical central lines and percutaneous

intravenous central lines

Mild to moderate respiratory distress syndrome
Suspected neonatal sepsis
Infants of diabetic mother


Care of infants of all gestational ages and weights; Mechanical

ventilation support, and possibly inhaled nitric oxide, for as long as

required immediate access to the full range of subspecialty consultation

Comprehensive on-site access to subspecialty consultants; Performance
and interpretation of advanced imaging tests, including computed
tomography, magnetic resonance imaging and cardiac echocardiography
on an urgent basis Performance of major surgery on site but not
extracorporeal membrane oxygenation, hemofiltration and

haemodialysis, or surgical repair of serious congenital cardiac

malformations that require cardiopulmonary bypass.

Severe respiratory distress syndrome
Persistent pulmonary HTN
Prematurity at<32 weeks
Major congenital malformations


Physical Organization

Personal Organization

Equipment Organization

The neonatologist and nurse incharge must be involved while planning the unit.
The intensive area should be localised preferably next to labour ward and
delivery rooms. For economising costs it would be preferably to have combined
with level 2 facilities, through both the areas there must have separate and
adequate staff and single administrative control. the neonatal unit can be
conceptualised in terms of four elements which exist in a concentric layering
inside outwards with designed work traffic flow pattern.
a) Clinical care areas
b) Clinical support areas

c) Administrative zones
d) Family support area
a) Clinical care areas

Scrubbing areas

Storage spaces

Hand washing scrub zones

b)clinical support areas


X ray machine

Formula preparation

TPN preparation

Breast milk expression

Equipment storage

Clean and dirty utility areas

c)Administrative and staff support areas

Central reception area

Separate unit office for ward master, resident doctor,and nursing

Staff changing room

On call duty doctor room

Staff rest room

Counselling room

Seminar rooms


1. Family support area

Children play area

Nourishment area

A lounge

Lockable storage

Education area


1. Bed strength
The NICU can be in a single area or it can be in multiple rooms with a capacity
of 2-4 infants intensive care bed is generally required for 100
deliveries provided the prematurity ratio is around 8 percent and hence for a
population of one million,30 intensive care beds would be required for our
country. It would be uneconomical to have a NICU of less than 6-8bed.
2. Space between the patient

For the patient care,100 square feet is required for each baby as it is true
for any adult bed

There should be a gap of about 6 feet between two incubators for

adequate circulation and keep the essential life saving equipments,space
needed about 120 square feet.

Each patient station should have 12-16 central voltage stabilised

electrical outlets

2-3 oxygen out lets

2 compressed air outlets

2 compressed air outlets

2-3 suction outlets

Additional power plug point would be required for the portable x-ray
machine close to the patient care area


In case of controlling the environmental temperature, the NICU should

not be located on the top floor, but there must be adequate sunlight for

The unit must have a fair degree or ventilation of fresh air through
central air conditioning is must. The temperature inside the unit should
be maintained at 28+_2deg c while the humidity must be above 50%.


The unit must have an uninterrupted clean water supply and each patient
care area must also have a wash basin with foot or elbow operated
tapes. Neat wash basin, placing paper towel and receptical.

The unit should be equipped with laminar air flow system, however
alternatively air conditioned with multipore filters and fresh air
exchange of 12 per hours should be provided.

The walls of the whole unit should be washable and have a white or slightly off
white colour for better colour appreciation of the neonates.
The lighting arrangement should provide uniform, shadow free illumination. In
addition spot illumination should be available for each baby for any procedure.
A generator back up is mandatory where there is frequent power fluctuations or
power failures.


The acoustic characteristics should be such that the intensity of light kept below
75 decibels. The unit should also have an intercom and a direct outside
telephone so that the parent of the patient can have an easy access to the medical
personnels in case of an emergency
Apart from the patient care area including rooms for isolation and procedures,
her e is need of space for certain essential functions, like a room for scrubbing
and gowning near the entrance, a side laboratory mothers room, adequate stores
for keeping consumable and non-consumable articles

A room for keeping x-ray and ultrasound machines

One or two rooms each would be needed for doctors and nurses on day
and night duties

There is space available for a biomedical engineer to provide essential

periodic preventive maintenance of costly equipments.

Additional space will be required for educational activities and storing

of data

Minimum of six air changes,2 air changes should be outside for filtering the
inner air.

Effective air ventilation of nursery is essential to reduce nasocomial


The air conditioning ducts must be provided with Millipore filters(0.5H)

to restrict passage of microbes



Easily cleaneable, protect at point with moveable equipment, made with

sound absorbable material


Easily cleanable with out use of hazardous material, minimize microbial



Easily cleanable, noise reduction


One emergency call bell in each room connected to doctors room


Computer ports with internet access should be readily available to

maintain database and data analysis.

Database of all NICU information, teaching aids like X rays, ECG, and
ABG reports must be maintained for future training and research.

Refers to the array of the medical gas outlet+electrical+data outlet at each
patient care station

Electric environment

Medical gases

Data outlets

16. Toilets
It is important to plan the number and position of water closets in the Neonatal
Unit. Parents bedrooms, Transitional Care, medical on-call rooms, and the area
dedicated to counselling (Parents Quiet Rooms) should all have separate toilet

facilities. In a large Neonatal Unit there should be at least 3 further toilets for
staff and the general public.
17. Transport incubator store

Transport incubators are bulky and should not be stored in public corridors.
There should be a designated area for storing them within the Equipment Store
18.Pneumatic tube system
Careful thought should be put into how specimens can be transferred urgently to
central laboratories in the Hospital. If a pneumatic tube system is chosen, it

should be easily accessible, robust and reliable. The outlet might be best
positioned at the central station next to the Unit Office. Readily available
personnel can then identify problems if the system were to fail to send an urgent
19. Stationery
Although some NNUs are striving towards becoming paperless, most will not
achieve this in the next five years. There should therefore be a room of 12 sqm
with extensive shelving for storage of all the paper sheets and forms necessary
for the efficient running of the NNU.
Pendants, gantries, cabinetry or head-rails?
Choosing to equip the rooms with pendants, gantries or cabinetry is a crucial
early decision. Pendants descend from the ceiling and are single-armed or
double-armed. The pendants contain intensive care facilities including electrical
outlets, oxygen and air pipes and a vacuum facility for suction. The clinician has
the opportunity of specifying the number of electric sockets, and the number of
shelves which are fixed to the pendant arms. These shelves can hold ventilators,
monitors, syringes drivers, and indeed any intensive care equipment required to
service the infants in the incubator.

Gantries have many of the advantages of pendants containing internally all the
pipin and wiring required to provide the oxygen, air, vacuum and power points
as well as the computer networks. The clinicians again have the opportunity of
specifying the number of sockets and the number of shelves. Many of the
gantries allow movement laterally of the hangars and ventilators, monitors and
syringe drivers can all be attached to the gantry.
If designed carefully, cabinetry is fully consistent with the demands of intensive
care. All intensive care and high dependency cots can be contained in spacious
bays. Electric sockets, computer and piped gas outlets can all be positioned so
that there is no interference with the movement of staff caring for the infant. It
is recommended that all such bays be identical in the Unit, so that staff can be
familiar with the work area no matter which room or cots have been allocated to
them. The size of the bays is critical. Each must accommodate an incubator, a
mother and father with comfortable seating, two members of nursing staff, and
it should be possible to manoeuvre all machinery (e.g. for taking X-rays) within
the allocated space. Such bays should be at least 3.2m wide and the bay walls
may extend 2-3 cm in room

It is possible to combine cabinetry systems with horizontal rails at the head of

the incubator. These rails then carry most of the intensive care monitoring
The NICU should be designed to allow efficient patient and staff movements
within the unit. The following should be included.
Ready access of the NNU to Labour Suite including Operating Theatres
All doors between Labour Suite and NNU, and also those within NNU, should
be designed to maximise safety and convenience. Automatic opening, push pad
opening, swipe-card access, punch-code access and manual opening may all be
appropriate in individual circumstances
Positioning of Neonatal intensive care cots closest to the Labour Suite
Access for mothers on trolleys or in wheelchairs. Widths of doors, corridors
and corners should be considered so that mothers have access to all clinical
Access to all cots in all clinical areas for X-ray, ultrasound and other mobile
equipment. An MRI scanner ideally should be available nearby on the same

Clinical support areas should be as close as possible to clinical care areas.

Such supports include near patient testing laboratory, pharmacy, equipment
storage, milk storage, clean and dirty linen store
Family access to the waiting area, counselling rooms, support services (e.g.
social work and community neonatal nursing) and recreational facilities
Positioning of the Clinical Managers office on the NNU floor, easily
available to all staff and, by arrangement, to families
Attending consultants office should be in the NNU so that family interviews
and staff interviews can take place readily
Doctors on call rooms should be in the NNU, sound-proofed, and sufficiently
distanced from busy corridors and extraneous noises to allow adequate rest
Consultant and research offices can be positioned further away from the
clinical care area
Ideally there should be ready access to the mortuary, a viewing area for the
bereaved, and to the autopsy suite.
The NNU should be thought of as babys first home. It must have a
welcoming atmosphere. This is achieved by thinking of the comforts of the

infant and family. Natural lighting and where possible views of the surroundings
outside are beneficial. Internal decoration can convert a clinical area into a room
which is appealing to families, and encourages all members of staff to treat the
care area as the infant bed room
MEDICAL STAFF-The unit should be headed by a director who is full time
neonatologist with special qualification and training in neonatal medicine.

He should be responsible for maintenance of standard of patient care

Development of operating budget

Equipment evaluation and purchase

Planning and development of education programme

Evaluation of effectiveness of perinatal care in the area

He should devote time to patient care services,research and teaching as

well as co-ordinate with level 1 and level 2 hospital in the area .


Neonatal physician 6-12 in the continuing care, intermediate care and

intensive care areas.

He should be available for 24 hrs basis for consultation

A ratio of one physician in training to every 4-5 patient who requires

intensive care ideal round the clock

Services of other specialists like micro biologists, hemtologists,

radiologists cardiologists and should be available on call.

An anaesthetist capable of administering anaesthesia to neonate

Paediatric surgeon and paediatric pathologists should be available


Nurse patient ratio of 1:1 maintained throughout the day and night

A ratio of one nurse for two sick babies not requiring ventilator support
may be adequate

For an ideal nurse patient ratio, four trained nurses per intensive care
bed are needed

Additional head nurse who is the overall incharge

In addition to basic nursing training for level 2 carer, tertiary care

requires dedicated committed and trained staff of the highest quality

The training must include training in handling equipment, use of

ventilators and the use of mask resuscitations and even endotracheal
intubation, arterial sampling and so on

The staff nurse must have a minimum of three 3yrs experience in special
neonatal care unit in addition to having three months training in a intensive care

One sweeper should be available round the clock

Laboratory technician

Public health nurse/social workers

Respiratory therapist

Bio medical engineer

Ward clerk can help in keeping track of the stores


Equipment and supports should include all that is necessary to

resuscitation and intermediate areas

Supply should be kept to the patient station so that nurse does not have
to go away from the neonate unnecessarily and nurses time and skills are
used efficiently

There should be controlled incubators and open air system for providing
adequate warmth

Adequate number of infusion pumps for giving fluid and parenteral

nutrition solutions and drugs should be available

Infant ventilators capable of giving pressure ventilation and various

cardiopulmonary monitor.


1. Radiant warmer
2. Incubator

3. Radiography
4. Oxygen catheter
5. Infusion pumps
6. Positive pressure ventilator
7. Oxygen analyser
8. Phototherapy
9. Electronic weighing machine
10. Transcutaneous PO2 and PCO2 monitor
11. Non invasive BP monitor
12. Invasive BP monitor
13. Intracranial pressure monitor.
14. Microdrips
15. Suction apparatus
16. Open care system
17. ECG monitor

18. Pulse oxymeter

19. Resuscitation set
20. Oxyhood
Disposable articles
21. Nasogastric tubes
22. Feeding bottles and cups.
23. Diapers.
24. Specimen bottles
25. I.V catheter
26. IV set,
27. Bacterial filters.
28. Three way stop cocks,
29. umbilical arterial and venous catheter,
30. syringes, needles,
31. ventilator tubes,

32. Canula,
33. Catheters suction, urinary ET tube, nasal catheters.
The unit should have printed problem oriented stationary for maintaining
records, admission and discharge slips
Record of all admission should be maintained in a register or on a computer
The information should be analyzed and discussed at least once a month to
improve the effectiveness of the nicu in providing the services
There should be continuing medical education programmes for
physicians and nurses in the form of lectures, demonstrations and group
This should cover important issues like resuscitation, steralisation to be
maintained for critically ill babies, putting in arterial catheters,
conducting exchange transfusions, maintenance of ventilators.
Educational programmes covering the nurses and physicians in the
community should be developed.
There should be regular discussion with the obstetrician to discuss the
perinatal care and condition Individual high risk cases
Education and follow up is necessary


A Neonatal nurse job role involves working in a specialist neonatal baby care
unit (within maternity or childrens hospitals) or in the local community.
Neonatal nurses care for new-born babies who are premature or are born sick.
There are a vast number of conditions that can affect a new-born baby and
require treatment from specialists within the healthcare team.
As a neonatal nurse its important to be sensitive to the needs of others, have a
caring attitude. As a neonatal nurse has an important role of supporting parents
of the sick baby at a time when they themselves are frightened of losing their
child, very anxious and stressed or upset seeing baby coupled up to wires and
monitors. As far as possible, the parents and occasionally other family members
are encouraged to take an active role in the care of the baby.
Managing patient care of newborns and pediatrics, assisting with the

admission assessment discharge of these patients;

Providing health education and counselling to patients;
Maintaining medical records
Participating in nursing and unit staff meetings and patient care conferences;
Performing other related duties as assigned/required.
Provides and/or manages the nursing plan of care for neonates with complex

Provides education, training, information, and consultation services to
physicians, registered nurses, and other members of the clinical team;
Interprets, coordinates, and implements new and existing policies, methods
and procedures for neonatal nursing in the Perinatal areas;
Keeps informed of current practices and trends and incorporates them into

Works in cooperation with other members of the multidisciplinary health

Makes professional contacts with a variety of public, private and professional
Performs other related duties as assigned/required.
The duties for a neonatal nurse may vary slightly at each hospital, but overall
their care tasks are the same. A neonatal nurse is one of the primary
caregivers of a baby in the intensive care unit, and often becomes the saving
grace to worried parents who have plenty of questions and few answers about
their situation.
General Care
One of the main duties for a neonatal nurse is the general care of the infant.
Babies, even tiny ones or those with physical ailments, need regular changes,
feedings and cuddles. Customarily, the NICU will assign each baby "care times"
throughout the day and night, usually about 3 or 4 hours apart from each other.
At each care time, the nurse will change the baby's diaper, take his temperature,
and feed him breast milk or formula. If a baby is receiving any medications,
these may also be administered during these times.
If the parents of an infant are able to visit regularly, a neonatal nurse will teach
them how to perform these basic cares. With time, nurses will help parents to
feel equipped in all aspects of meeting their little one's needs and will continue
to serve as a basic support system during the hospitalization.

Special Needs
Sometimes babies are too fragile or small to eat directly from breast or bottle.
When this is the case, they are fed either intravenously, or through a gavage
tube, which is a small tube that goes from the nose or mouth into the stomach.
Nurses will carefully place the correct amount of formula or dietary
supplementation if a baby is not yet eating, into either of these methods of
nutrition, and monitors the baby for any positive or negative changes in the
The duties for a neonatal nurse also include inserting and changing IVs,
administering blood transfusions when necessary, and drawing blood for various
testing. Nurses are able to perform many other procedures as well, and it fully
depends upon each hospital's individual protocol, as well as the nurse's
experience level and staff rating.
Technical Duties for a Neonatal Nurse
Regardless of their other responsibilities, all neonatal nurses do a fair bit of
charting on each of their patients. This may be on a paper sheet, or more
commonly every year, completed electronically via a special hospital computer
system. The details logged into the online chart allow doctors, other nurses, and
anyone else within the baby's medical care team to view a baby's updated health

A nurse may also be responsible for emailing the neonatologist (NICU doctor)
or calling the parents with specific requests or information. While a neonatal
nurse's priorities are found in caring for the child assigned to them, they often
also spend a large portion of their shift charting and getting messages out to
those who need to receive them.
Emotional Support
A neonatal nurse often gets to know the families of infants very well, especially
if they happen to have a primary baby they take care of. A primary nurse will
care for the same infant for the duration of his hospital stay, whenever he/she is
on shift. This works well, as the nurses become very familiar with their babies
and can in turn provide them with the best care possible.
In building relationships with these families, they can often provide emotional
support and comfort during scary times. If a baby has to go through surgery or
is exceptionally ill, nurses are great for reassuring the parents and providing as
concrete of answers as they are permitted to.
Neonatal nurses are often the unsung heroes to families and able to give the
earliest of lives a fighting chance. Their daily duties add up to countless
miracles and a rewarding career at the same time.

A neonatal intensive-care unit (NICU), also known as an intensive care
nursery (ICN), is an intensive-care unit specializing in the care of ill or
premature newborn infants. A NICU is typically directed by one or more
neonatologists and staffed by nurses, nurse practitioners, pharmacists, physician
assistants, resident physicians, and respiratory therapists, dietitians. Many other
ancillary disciplines and specialists are available at larger units. Neonatal
intensive care is costly not only to the individual but also to the family. These
cost increase with decreasing birth weight and gestational age. Therefore
neonatologists must include parents in any discussion about whether to continue
the extreme measures being provided to their extremely low birth weight
preterm infants. Development of neonatal intensive care unit requires careful
planning with the joint efforts of physicians, nurses and architects. The plan
should be based on functional efficiency. Neonatal intensive care unit ideally
should be next to the obstetric suite.

Journal of Health Population & Nutrition. 2011 Oct;29(5):500-509

(1) Assessment of special care newborn units in India.

The neonatal mortality rate in India is high and stagnant. Special Care Newborn
Units (SCNUs) have been set up to provide quality level II newborn-care
services in several district hospitals to meet this challenge. The units are located
in some remotest districts where the burden of neonatal deaths is high, and
access to special newborn care is poor. The study was conducted to assess the
functioning of SCNUs in eight rural districts of India. The evaluation was based
on an analysis of secondary data from the eight units that had been functioning
for at least one year. A cross-sectional survey was also conducted to assess the
availability of human resources, equipment, and quality care. Descriptive
statistics were used for analyzing the inputs (resources) and outcomes
(morbidity and mortality). The rate of mortality among admitted neonates was
taken as the key outcome variable to assess the performance of the units. Chisquare test was used for analyzing the trend of case-fatality rate over a period of
3-5 years considering the first year of operationalization as the base. Correlation
coefficients were estimated to understand the possible association of casefatality rate with factors, such as bed:doctor ratio, bed:nurse ratio, average
duration of stay, and bed occupancy rate, and the asepsis score was determined.
The rates of admission increased from a median of 16.7 per 100 deliveries in
2008 to 19.5 per 100 deliveries in 2009. The case-fatality rate reduced from 4%
to 40% within one year of their functioning. Proportional mortality due to sepsis
and low birth weight (LBW) declined significantly over two years (LBW <2.5

kg). The major reasons for admission and the major causes of deaths were birth
asphyxia, sepsis, and LBW/prematurity. The units had a varying nurse:bed ratio
(1:0.5-1:1.3). The bed occupancy rate ranged from 28% to 155% (median
103%), and the average duration of stay ranged from two days to 15 days
(median 4.75 days). Repair and maintenance of equipment were a major
concern. It is possible to set up and manage quality SCNUs and improve the
survival of newborns with LBW and sepsis in developing countries, although
several challenges relating to human resources, maintenance of equipment, and
maintenance of asepsis remain.
- By Malhotra S & Mohan P.

(2) Challenges in scaling up of special care newborn units-lessons from India.

Indian Journal of Pediatrics. 2011 Dec;48(12):931-935.
Neonatal mortality rate in India is high and stagnant. Special Care
Newborn Units (SCNUs) are being set up to provide quality level II newborn
care services in district hospitals of several districts to meet this challenge. The
units are located in some of the remotest districts where the burden of neonatal
deaths and accessibility to special care is a concern. A recently concluded
evaluation of these units indicates that it is possible to provide quality level II
newborn care in district hospitals. However, there are critical constraints such as
availability and skills of human resources, maintenance of equipment and bed
occupancy. It is not the SCNU alone but an active network of SCNU (level II
care), neonatal stabilization units (level I care) and newborn care corners can

impact neonatal mortality rate reduction higher. Number of beds is also not
sufficient to cater to the increasing demand of such services. Available number
of nurses is a problem in many such units. An effective and sustainable system
to maintain and repair the equipment is essential. Scaling up these units would
require squarely addressing these issues.
- By Neogi S & Zodpey S

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