1. Shelly Gray OB Transitioning Into Family-Centered Care Changing the Model of Care on the Maternal-Child Unit at San Jacinto Methodist Hospital Kay Noster Nursery March 28, 2013 Baytown, Texas

2. Shelly Gray and Kay Noster March 28, 2013 Baytown, Texas San Jacinto Methodist Hospital’s Maternal-Child Mission Statement: Recommendations from Experts The benefits of keeping moms and babies together are so impressive that many professional organizations have made recommendations promoting skin-to-skin contact and rooming-in and opposing routine separation of mothers and babies after birth. These organizations include the Academy of Breastfeeding Medicine (ABM Protocol Committee, 2007); American Academy of Pediatrics (AAP Expert Workgroup on Breastfeeding, 2005); the American College of Obstetricians and Gynecologists (ACOG Committee on Health Care for Underserved Women & Committee on Obstetric Practice, 2007); the Association of Women’s Health Obstetric and Neonatal Nurses (2000); the World Health Organization (1998); and the International Lactation Consultant Association (1999).

3. Why Family-Centered Care? Several factors contribute to women's retrospective attitudes toward their birth experience. The most prominent factors include control, choice in decision making, social support, and efficacy of pain control (Cook, 2012). In a quality improvement project in which early skin-to-skin contact was utilized in the operating room and during recovery “healthy infants born by cesarean who experienced STS in the OR had lower rates of formula supplementation in the hospital (33%), compared to infants who experienced STS within 90 minutes but not in the OR (42%), and those who did not experience STS in the first 90 minutes of life (74%) (Hung, 2011). Studies show that hospital practices that promote mother and baby being together have a positive influence on mother–infant interaction on day 4, and on maternal affectionate behavior (kissing, smiling, talking to, and looking at the baby), on the babies’ behavior (smiling, laughing more, and crying less) at 1 to 3 months postpartum, and on the duration of breastfeeding” (Bystrova, et al., 2009). Rooming-in has been shown to promote exclusive breastfeeding and longer breastfeeding duration. Babies who room-in are more likely to take in more breast milk and gain more weight per day and are less likely to become jaundiced. 3 Transitioning Into Family-Centered Care Family-Centered Care is defined as “an orientation to the delivery of health care and supportive services that considers a person’s needs, goals, preferences, cultural traditions, family situation, and values” (Levine, 2012). Family-Centered Care “also recognizes and addresses family needs and preferences, and integrates family caregivers as partners in care” (Feinberg, 2012).

4. Implementing Skin-to-Skin Guidelines in Routine Nursing Care 4 Transitioning Into Family-Centered Care Our goal is to implement skin-to-skin within 5 minutes of birth (unless otherwise medically indicated). Parents will be encouraged to keep babies skin-to-skin for at least the first hour after birth. The World Alliance for Breastfeeding Action's Web site states that breast-feeding within the first hour of birth "is the first and most vital step" toward reducing the nation's neonatal mortality rate. “The closeness between mother and infant during the first hours after birth promotes maternal behavior and ties between mother and young” (Bystrova, et al., 2009).

5. Two New Nursing Roles Will Be Created 5 Transitioning Into Family-Centered Care Transition NurseFamily Nurse This role will traditionally be filled by a nursery nurse. This nurse will attend all deliveries and monitor the baby for 2 hours post delivery. Will take care of up to 3 stable postpartum mothers and up to 3 stable newborns. All routine medications and vital signs will be obtained within this 2 hour timeframe. Infant’s weight and measurements may not be taken immediately after delivery, but around the end of the first hour after delivery.

6. 6 Before Delivery the nurse will: Talk with the patient and family about the importance of skin-to-skin after delivery. Discuss with the physician or midwife the intent to place baby skin-to-skin after delivery. Remove all bras prior to admission to facilitate placing the baby skin-to-skin. After Delivery the nurse will: Place a warm blanket/towel on mother’s abdomen, dry infant off with warm towel, and bulb suction as needed. Remove wet blanket. Once cord is cut, place infant prone between mother’s bare breasts. Place diaper and hat on baby. Cover mother and baby with a warm blanket. If needed, the baby will be placed on the warmer for a quick dry off and visual assessment. The infant will then be placed immediately back on mother’s chest. If oxygen is needed, the baby will be placed on the warmer, oxygen will be administered as needed, and a pulse oximeter will be placed. As soon as the baby is weaned to room air, the baby will be placed back on mother’s chest. Pulse oximeter may remain on baby. During the 1 st hour Apgars will be completed, ID bands will be placed, vital signs will be assessed, and the security tags will be placed. At the end of the 1 st hour, the weight and measurements will be taken, footprints will be obtained, crib card will be created, ballard exam will be performed, and standard medication will be given. The time skin-to-skin was initiated and ended will be documented. The Role of the Transition Nurse Transitioning Into Family-Centered Care

7. 7 Flyers for Patients Explaining Family-Centered Care to be given Prior to Admission Optional Flyers for Patients to Display on Door to be Given On Admission Flyers for Patients Explaining Skin-to-Skin Contact to be Given On Admission

8. Transitioning Into Family-Centered Care Your physician, your hospital, and your nurse are committed to providing you with the best care possible. We value your opinion, and we understand the importance of family. San Jacinto Methodist Hospital is committed to providing you and your loved ones with the best birthing experience possible. We recognize the importance of this special event in your life, and are dedicated to making these memories special for you and for your family. Flyers for Patients Explaining Family-Centered Care to Be Given Prior to Admission

9. 9 Transitioning Into Family-Centered Care Optional Flyer for Patient to be Displayed on Door to be Given On Admission

10. The Importance of Skin-to-Skin Contact BENEFITS FOR YOU. BENEFITS FOR YOUR NEWBORN. WHAT IS SKIN-TO-SKIN? SKIN-TO-SKIN CONTACT MEANS PLACING YOUR INFANT DIRECTLY AGAINST YOUR BARE CHEST. IT IS ESPECIALLY RECOMMENDED IMMEDIATELY AFTER DELIVERY. BENEFITS FOR THE NEWBORN The initial closeness skin-to-skin contact provides helps a newborn feel secure. Newborns who are held skin-to-skin release less stress hormones, cry less often and react better to their environment. Skin-to-Skin contact also helps to regulate all of a newborn's vital signs. A baby's temperature, blood sugar level, respirations, hear rate, and oxygen saturation are all more stabilized when a mother holds her infant close to her after birth. Evidence also shows that skin-to-skin contact is just as effective as a radiant warmer at stabilizing an infant's temperature, and temperature regulation is vitally important to newborn adaptation. What is all the fuss about? BENEFITS FOR THE MOTHER Placing your newborn directly against your skin after delivery releases endorphins, which cause a mother to "feel good" and more relaxed after delivery. The production of the hormone Oxytocin is increased when a mother holds her newborn close to her. This hormone helps a mother bond with her baby. In addition, Oxytocin helps your uterus to contract, which minimizes bleeding postpartum. Physicians are all in agreement... they recommend exclusively breastfeeding your infant for the first six months of a newborns life. SKIN-TO-SKIN AND IT'S IMPACT ON BREASTFEEDING Mother's who utilize skin-to-skin contact after delivery are more likely to be successful at breastfeeding. Babies who are held skin-to-skin latch on earlier, latch-on easier, and breastfeed longer. Mothers also make more breast milk and are 60% more likely to be exclusively breastfeeding at six months. Milk that is MILK Is Skin-to-Skin Contact For Me? Ask your nurse for more information to see if skin-to-skin contact is right for you. Flyers for Patients Explaining Skin-to-Skin Contact to be Given to On Admission Transitioning Into Family-Centered Care

11. Changes Families Can Anticipate 11 Transitioning Into Family-Centered Care Patients will be informed of their physician’s, their hospital, and their nurse’s commitment to Family- Centered Care. Patients will be shown how to perform basic parenting skills, such as bathing their babies, in order to provide patients with the necessary tools to successfully transition into parenthood. Fathers will be engaged to actively care for their babies from birth, which includes participating in infant care skills. Fathers will be offered the same opportunities for bonding with their babies, such as skin-to-skin contact. Patient will be informed of what Family-Centered Care means, why it’s important, and how it helps to promote positive outcomes. Patients will be informed that mothers get more sleep when their infants are near them. This also facilitates the early initiation of breastfeeding (Weddig, 2011). Patient’s will be encouraged on admission to utilize skin-to-skin contact and the importance of skin-to-skin contact throughout their hospital stay will be discussed. Mother’s will be encouraged to breastfeed on demand.

12. Changes Physicians Can Anticipate All patients will be educated on the importance of family-centered care and skin-to-skin contact on admission and during their hospital stay. Hand-out material will be provided to physicians to better prepare their patients for the changes to be implemented. All patients will be required to keep healthy newborns in their rooms. Fresh cesarean- section patients who do not have family support will be allowed to keep their babies in the nursery. Infants will no longer be brought to the nursery to be assessed by the physician. Infants will only be brought to the nursery for certain procedures, such as circumcisions. All healthy newborns will be placed skin-to-skin after delivery. This option will be available to mothers who are undergoing a cesarean section. Sleep-aids, such as Ambien, will be removed from standard postpartum orders. All patients will be informed of our commitment to promoting the best birthing experience and our commitment to family-centered care. 12 Transitioning Into Family-Centered Care

13. Change is Hard!  We must stay focused. Our patients deserve to be provided with the best care available. We are on a mission to change a unit, a hospital, and most importantly, a community. Our goal is to empower patients to be advocates for their health, and for the health of their newborn, and to provide our patients with the best possible skills to successfully transition into parenthood.

14. References Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A., Ransjö-Arvidson, A., Mukhamedrakhimov, R., &... Widström, A. (2009). Early contact versus separation: effects on mother--infant interaction one year later. Birth: Issues In Perinatal Care, 36(2), 97-109. doi:http://dx.doi.org/10.1111/j.1523- 536X.2009.00307.x Cook, K., & Loomis, C. (2012). The Impact of Choice and Control on Women's Childbirth Experiences. Journal Of Perinatal Education, 21(3), 158-168. doi:http://dx.doi.org/10.1891/1058-1243.21.3.158 Crawford, D. (2012). Evidence vs family-centred care. Nursing Children & Young People, 24(10), 3. Feinberg, L. (2012). Moving Toward Person- and Family-Centered Care. Washington, DC: AARP Public Policy Institute. www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2012/moving-toward- person-and-family-centered-care-insight-AARPppi-ltc.pdf. Retrieved September15, 2012.www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2012/moving-toward- Gallagher, H., & Wise, S. (2012). Fathers at birth and beyond. Midwives, 15(4), 48-49. Hung, KJ. (2011). Early skin-to-skin after cesarean to improve breastfeeding. American Journal of Maternal Child Nursing. 2011 Sep-Oct;36(5):318-24; quiz 325-6. doi: 10.1097/NMC.0b013e3182266314. Levine, C., & Feinberg, L. (2012). Transitions in Care: Are They Person- and Family-Centered?. Generations, 36(4), 20-27. Weddig, J., Baker, S. S., & Auld, G. (2011). Perspectives of Hospital-Based Nurses on Breastfeeding Initiation Best Practices. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 40(2), 166-178. doi:http://dx.doi.org/10.1111/j.1552-6909.2011.01232.x