Welcome to the Newborn Nursery

Erin Burnette, NP-CEmily Freeman, CPNP

Jamie Haushalter, CPNP

Objectives• Recognize the important factors in the maternal history and labor/delivery process which

may affect the newborn. These factors include: pertinent social issues, chronic medical conditions in the mother, genetic risk factors, maternal/infant Rh/ABO status, maternal drug use, maternal infection, type of delivery, APGAR scores, etc.

• Develop novice competence in the examination of the newborn infant. This includes recognition of normal and abnormal physical characteristics and estimation of gestational age.

• Develop practical knowledge of the following topics and demonstrate competence in using such knowledge to counsel families about routine newborn care:

– Prevention of cross infection it the nursery– Breast and bottle feeding– Parental counseling in routines of newborn care.– Recognition of psychosocial factors that may affect maternal/infant interaction– Circumcision– Newborn screening

• Verbalize appropriate utilization of protocols for the newborn infant (hypoglycemia, hyperbilirubenemia, DDH, toxicology).

Newborn Orientation Guide

• Schedule, pre-rounding, gathering of information

• Gestational age growth curve/percent-change.com

• Bili curve/Bilitool.com• GBS protocol• Hypoglycemia protocol• Drug screening protocol

Basics• Standard of care is “rooming in”• Try to minimize disruptions to

maternal-infant bonding. • Encourage and promote

breastfeeding• Quiet time

• 2-4 pm

"Happy Crisis" by W. Brown

“Happy Crisis”• Happy Crisis of new parents• You as the Physician• Perception is Reality

– Importance of how you say, as well as what you say

• Your Comfort Zone• You are not the only source. We want

you to ask questions

"Happy Crisis" by W. Brown

FIRST ENCOUNTER“You never get a second chance to make a

first impression.” H&S Commercial• Newborn Exam through the eyes of a

parent• Do your homework:

• Know your patient and parent• Call infant by his/her name

• Clearly Identify Self• Know the Players in the Room

"Happy Crisis by W. Brown

PRESENTATIONKeep it Simple [KISS Principle]• Questions/Concerns without answers

–Yours and theirs–Have a positive definitive plan–Follow thru at expected time re:

hyper- concerns of the new parents.

• Don’t share your concerns unless there is a definitive plan

Neonatal Jaundice• Almost all newborns will develop jaundice in the first few

days of life• All babies are screened using a transcutaneous bilirubin

(TCB) monitor at 18-22 hours of life– If the initial TCB at this time is ≥ 7 nursing will order a neonatal

(serum) bilirubin level (AKA “neobili”) with NBS.– Trust your clinical judgment.

• TCB prior to discharge.

Hyperbilirubinemia

Risk for hyperbiliwww.bilitool.org

SpO2 screening for Critical Congenital Heart Disease

• All infants need to be screened for Critical Congenital Heart Disease (CCHD) prior to discharge.

• Infant’s >18 hours of life need to have a SpO2 level checked in their right hand and either foot.

• Infant passes if >95% and less than 3% difference between hand and foot.

Algorithm

Pulse Ox on Right Hand (RH) and One Foot After 18 Hours of Age

Hypoglycemia Protocol• Late Preterm: 34-36 6/7 weeks; SGA: <2500g; LGA: >4000g; IDM:

medication OR diet controlled. • LIP may ask for protocol to be initiated if infant is LGA or SGA

once plotted on growth chart, or if other risk factors are present. • Goal is 3 consecutive blood glucose levels ≥41 from birth-4hrs or

≥46 after 4hrs of life. • May need to offer hand expressed colostrum, donor breast milk

or formula as medically indicated for treatment of hypoglycemia. • Please see algorithm for s/sx of hypoglycemia or other reasons to

consider initiation of the protocol.

Late Preterm Infant

• Infants between 34-36 6/7 weeks gestation will follow the late preterm infant pathway (review on curriculum website)

• Close monitoring of feedings, jaundice, weight, and temperature during hospital stay.

• No discharge prior to 48 hours.• Special crib card, baby tracker, parent booklet• Parent education

Neonatal Abstinence Syndrome• Toxicology screens should be performed on at-risk infants

(maternal hx of drug use, late/insufficient prenatal care, unexplained IUGR, etc. please refer to Guidelines for Infant Drug Screening)

• Urine and meconium toxicology screens should be ordered and obtained early, most accurate if they are from the first void or stool.

• Infants exposed to opiates in utero are at risk of withdrawal. • Opiate weaning scoring should be obtained every 4 hours• Non pharmacological measures (swaddling, sucking, quiet

environment, etc. should be implemented early)• Morphine needed for 3 scores >8 or 2 scores >12

Breastfeeding

• Breastmilk is best for most infants• True contraindications: HIV positive mother, cocaine

use• Lactation consultants meet with every mother• Mothers should feed when infant demonstrates

hunger cues and/or every 2-3 hours. 8-10 feedings per day.

• Colostrum initially, milk comes in after delivery (timing depends on type of delivery/#of pregnancies)

Daily Tasks• Pre-rounding:

– Filling out a new patient card– Obtaining daily information for interim babies– Discharge information

• Morning report/grand rounds• Walk Rounding with Resident/attending• Noon conference/lunch• Afternoon:

– Education with attending 1300/1500– Admitting of new babies– Follow up of any outstanding issues

NBN Cards

• Gather information on admission from:– Moms chart: webcis for labs, H&P, ultrasound

reports, etc; echart (L&D summary and Intrapartum singleton notes)

– Babys chart: webcis for labs, echart for measurements, vital signs

• On interim days, review/update:– Infant weight, voids/stools, bili checks, lactation

notes, immunizations, hearing test, newborn screen

The Board

• You will find:– Babies name, room #, c/s, birth time– Service (UNC, FP, PHS, etc)– Completion of Hep B, hearing test, NBS, circ….– Other information such as SW consult, formula

feeding, etc.

Don’t hesitate to ask

questions!