1. Impending Delivery Skin-to-Skin in the Labor Room
The Mizzou Standard of Care
Call 4th Floor and transition nurse (TN) to
alert them of impending
delivery
Impending Delivery
May Breastfeed
Nurse remain with infant
Observe until stable
Respiration 60-70
O2 Sat > 85
Infant actively rooting
No grunting, flaring, retracting
YES
Baby is born &
immediately goes to chest
Mother/Baby
candidate for immediate
S2S? NO
Newborn is quickly dried and placed bare
inside gown against mom’s bare chest (no bra)
Observe infant
Baby can remain skin-to-skin
No feeding
Baby to Resuscitation
Room
Respirations >60
O2 Sat > 85
Mild grunting, flaring, retractions
Respiratory Instability?
Baby Stable? NO
Inform mother of
baby’s status and where
the baby is going
YES
Baby remains S2S whileTN/Baby Nurse
continually assesses:
Breathing
Color
Tone
Cry
Stability of infant on chest
Baby Nurse bulb suctions and stimulates as needed
Respirations >70
O2 Sat below target range
Significant grunting, flaring, retractions
Resuscitation Team
works with infant
Temperature Instability in
1st 30 minutes of life?
Infant Stabilized?
YES
Notify Physician, Infant to NOU/NICU
Keep mother up to date
on baby’s progress – begin
pumping and hand expressing
in recovery room (within 3 hours) NO
What is the issue?
Prior to 1 hour of life:
1 - Administer Erythromycin eye ointment
and Vitamin K injection
2 – Perform second set of vitals
Temp ≤ 36.3
Temp > 38?
Send colostrum to NICU/NOU for oral care or feeds
Ensure baby prone on mothers chest between breasts
Replace dry warm blankets on baby and replace hat
Increase room temperature
Recheck temp in 30 minutes
Are any of the following Present?
Maternal temp > 38.0
GBS pos and no ABX
Risks for Chorio
ABX received in labor
<36 weeks gestation
Prolonged ROM (>18 hrs)
Newborn remains skin to skin at
least one hour (if baby
has not latched at one hour, baby remains
S2S until 1st feed complete)
Record in chart:
Hand expression taught
Time that pumping/hand
expression performed
Temp > 36.3? NO
YES
YES
Teach mother:
Feeding cues
Importance of S2S
Biologic Hold
Hand expression
Assist baby in latch NO
Encourage mother
to do S2S immediately
upon being reunited
with her infant
Resume normal care
Check bedside glucose
Infant to warmer
Call infant healthcare provider
Monitor
Recheck temp for one hour
Call Provider
Concerning Vitals
Vital signs outside the parameters below
warrant an assessment, intervention,
and reevaluation. Interventions must be
documented in the chart.
Temp < 36.3
Temp > 37.5
HR < 100
HR > 170
Resp < 35
Resp > 65
Blood glucose <40
Infant is weighed
Temp < 38 w/i one hour
Temp remains > 38 for one hour
Once mother/infant stable and PACU nurse
comfortable,
call up report to NOU and record information:
Record that infant went S2S within 5 minutes
Record infant vitals (30 and 60 minutes)
Record newborn weight
Call Provider
Resume Normal Care
Infant transferred to 4th floor in mother’s arms
Immediate S2S Candidates
Gestational Age >34 6/7 weeks gestation No chest compressions
Cord gas pH >7.0
No chorioamnionitis
Absence of meconium
Absence of operative delivery
Newborn bath and assessment occur in mother’s room
(delay until there is time and the mother can
participate) cs