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 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.

9. Hyperbilirubinemia

10. Risk for hyperbili www.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: 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!