Welcome to the Newborn Nursery

1. Welcome to the Newborn Nursery Erin Burnette, NP-C Emily Freeman, CPNP Jamie Haushalter, CPNP

2. 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).

3. 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

4. Basics • Standard of care is “rooming in” • Try to minimize disruptions to maternal-infant bonding. • Encourage and promote breastfeeding • Quiet time • 2-4 pm

5. “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

6. 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

7. PRESENTATION Keep 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 "Happy Crisis by W. Brown

8. Neonatal Jaundice • Almost all newborns will develop jaundice in the first few days of life • All babies are screened using a transcutaneousbilirubin (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.

9. Hyperbilirubinemia

10. Risk for hyperbiliwww.bilitool.org

11. 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.

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

13. 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.

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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.

21. Don’t hesitate to ask questions!