I. ADMISSION TO THE NEWBORN NURSERY. Healthy newborns may room-in with their mothers all or nearly all the time while they remain in the hospital. Every effort should be made to avoid separation of mother and infant especially during the first hour of life (the “golden hour”) in order to promote immediate initiation of breastfeeding and early bonding through skin-to-skin contact. Delaying birth weight measurements is acceptable to allow the opportunity to breastfeed. These recommendations follow the global Baby-Friendly Initiative of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to strengthen maternity practices and improve exclusive breastfeeding. Family-centered maternity care, in which the nurse cares for the mother and baby together in the mother’s room (couplet care), facilitates teaching and helps support this Baby-Friendly Initiative.

A. Criteria for admission to the normal newborn nursery or couplet care with the mother vary among hospitals. The minimum requirement typically is a well-appearing infant of at least 35 weeks’ gestational age, although some nurseries may specify a minimum birth weight, for example, 2 kg.

B. Security in the nursery and mother’s room is necessary to protect the safety of families and to prevent the abduction of newborns.

1. Many nurseries use electronic security systems to track newborns.

2. Identification (ID) bands with matching numbers are placed on the newborn, mother, and father/partner/support person as soon after birth as possible. Transport of infants between areas should not occur until ID banding has been confirmed.

3. All staff are required to wear a picture ID badge, and parents should be instructed to allow the infant to be taken only by someone wearing an appropriate ID badge.

A. The transitional period is usually defined as the first 4 to 6 hours after birth. During this period, the infant’s pulmonary vascular resistance decreases, blood flow to the lungs is greatly increased, overall oxygenation and perfusion improve, and the ductus arteriosus begins to constrict or close.

B. Interruption of normal transitioning, usually due to complications occurring in the peripartum period, will cause signs of distress in the newborn.

C. Common signs of disordered transitioning are the following:

1. Respiratory distress +/− cyanosis

2. Poor perfusion

D. Transitional care of the newborn can take place in the mother’s room or in the nursery.

1. Infants are evaluated for problems that may require a higher level of care, such as gross malformations and disorders of transition.

2. The infant should be evaluated every 30 to 60 minutes during this period. This evaluation includes the assessment of heart rate, respiratory rate, and temperature; assessment of color and tone; and observation for signs of withdrawal from maternal medications.

3. When disordered transitioning is suspected, a hemodynamically stable infant can be observed closely in the normal nursery setting for a brief period of time. Infants with persistent signs of disordered transitioning require transfer to a higher level of care.

A. Rooming-in should be encouraged during the infant’s hospital stay. When possible, physical assessments, administration of medications, routine laboratory tests, and bathing should occur in the mother’s room. For family-centered maternity care, nursing ratios should not exceed 1:4 mother-baby couplets.

1. Upon admission to the nursery, the infant’s weight, head circumference, and length are recorded. On the basis of these measurements, the infant is classified as average for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA) (see Chapter 7).

2. If the gestational age of the infant is uncertain, an assessment of gestational age can be performed using the expanded Ballard score (see Chapter 7).

B. The infant’s temperature is stabilized with one of the following modalities:

1. Skin-to-skin contact with the mother

2. Open radiant warmer on servo control

C. Universal precautions should be used with all patient contact.

D. The first bath is given with warm tap water and nonmedicated soap after an axillary temperature >97.5°F has been recorded.

E. There are several acceptable practices for umbilical cord care. Dry cord care is generally sufficient and has not been shown to increase infection rates in
developed countries. However, antiseptics, such as alcohol or triple dye, or topical antibiotics can be considered if there is concern for infection. Keeping the cord dry also promotes earlier detachment of the umbilical stump.

A. All newborns should receive prophylaxis against gonococcal ophthalmia neonatorum within 1 to 2 hours of birth, regardless of the mode of delivery. Prophylaxis is administered as a single ribbon of 0.5% erythromycin ointment bilaterally in the conjunctival sac (see Chapter 49). Although 1% tetracycline ointment is equally effective, it is not available in the United States.

B. A single, intramuscular dose of 0.5 to 1 mg of vitamin K (phytonadione) should be given to all newborns before 6 hours of age to prevent vitamin K deficiency bleeding (VKDB). Currently available oral vitamin K preparations are not recommended because late VKDB (which occurs at 2 to 12 weeks of age) is best prevented by the administration of parenteral vitamin K (see Chapter 43).

C. Administration of the first dose of preservative-free, single-antigen hepatitis B vaccine is recommended for all infants during the newborn hospitalization, even if the mother’s hepatitis B surface antigen (HBsAg) test is negative (see Chapter 48).

1. Hepatitis B vaccine is administered by 12 hours of age when the maternal HBsAg is positive or unknown. Infants of HBsAg-positive mothers also require hepatitis B immune globulin (see Chapter 48).

2. The vaccine is given after parental consent as a single intramuscular injection of 0.5 mL of either Recombivax HB (5 µg) (Merck & Co, Inc, Whitehouse Station, New Jersey) or Engerix-B (10 µg) (GlaxoS-mithKline Biologicals, Rixensart, Belgium).

3. Parents must be given a vaccine information statement (VIS) at the time the vaccine is administered. Updated VIS, in English and in other languages, is available at http://www.cdc.gov/vaccines/hcp/vis.

A. Prenatal screening test results should be reviewed and documented on the infant’s chart at the time of delivery. Maternal prenatal screening tests typically include the following:

1. Blood type, Rh, antibody screen

2. Hemoglobin or hematocrit

3. Rubella antibody

4. HBsAg

5. Serologic test for syphilis (Venereal Disease Research Laboratory [VDRL] or rapid plasmin reagin [RPR])

6. Group B Streptococcus (GBS) culture

7. Human immunodeficiency virus (HIV)

8. Gonorrhea and Chlamydia cultures

9. Glucose tolerance test

10. Antenatal testing results, including multiple marker screenings, and ultrasonography results

11. Cystic fibrosis carrier testing

B. Screening for neonatal sepsis risk

1. All newborns should be screened for the risk of perinatally acquired GBS disease (see Chapter 49) as outlined by the Centers for Disease Control and Prevention. Risk factors for early-onset neonatal sepsis include maternal GBS colonization in the genitourinary or gastrointestinal tract, gestational age <37 weeks, inadequate GBS prophylaxis, maternal intrapartum temperature ≥100.4°F (38°C), rupture of membranes >18 hours, and signs of chorioamnionitis.

2. Penicillin is the preferred intrapartum chemotherapeutic agent. Intravenous intrapartum administration of penicillin, ampicillin, or cefazolin (for penicillin-allergic women without history of anaphylaxis) ≥4 hours before delivery provides adequate neonatal prophylaxis. Penicillinallergic women at high risk for anaphylaxis should receive clindamycin or vancomycin; erythromycin is no longer recommended.