Second Shift Holiday Neonatal Code: A Recipe for Stress


Poster Presentation


Obstetric and neonatal staff felt extremely frustrated and stressed during a neonatal resuscitation. Frustration and tension among code team members affected communication and the team's effectiveness.


A 31-year-old multigravida presented via ambulance to labor and delivery at a community hospital with spontaneous rupture of membranes of muddy amniotic fluid at 8 cm dilatation. The patient was flailing her arms and legs uncontrollably, compromising the accuracy of maternal and fetal heart rate assessments. Initial fetal heart tones were in the 50 seconds and the maternal pulses were palpated in the 70 seconds. The obstetrician was notified immediately. A male infant born via spontaneous vaginal delivery was limp and cyanotic. The neonatal intensive care unit (NICU) staff was notified. Unique nursing challenges during this code included door-to-delivery time 13 minutes, unassisted RN delivery, nightshift holiday with limited staffing, patient presented alone, and physician call-to-arrival-time 30 minutes with no in-house obstetric physician presence.

The neonate required compressions, intubation, multiple epinephrine doses, and fluid boluses during the 23-minute code. The team was frustrated at their inability to locate emergent supplies in a timely fashion from the newly initiated neonatal code box and their roles during the resuscitation. Additional staff were required to assist. The nursing supervisor and respiratory staff were not initially present during the code because the overhead code announcement was not initiated.


Multiple interdisciplinary debriefings were held to gather information and to support staff involved in the code. Nursing/physician leadership identified system/process issues from these debriefings. Strategies were developed to reduce staffs’ frustration, tension, and feelings of chaos, including reassignment of code team member responsibilities, implementation of routine code drills that included staff from all shifts and all team member departments, and the initiation of timed neonatal code box drills to increase code box familiarity. Staff assisted in developing a code checklist that facilitated communication during and after a neonatal code.

Staff felt more confident in their roles and responsibilities as code responders. Team members felt more effective, less stressed, and better prepared for the unexpected. Empowering staff and increasing knowledge does decrease frustration and tension during unanticipated and challenging neonatal codes.