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Policy Name
Policy Number
Date this Version Effective
Responsible for Content
I. Description
Outlines the care of the newborn immediately following birth and during hospitalization, including
thermoregulation, oxygen therapy in emergent situations, hypoglycemia, phototherapy, and
circumcision.
Table of Contents
I. Description ....................................................................................................................................... 1
II. Rationale.......................................................................................................................................... 1
III. Policy/Procedure .............................................................................................................................. 1
A. Policy ......................................................................................................................................... 1
B. Procedure .................................................................................................................................. 2
Newborn Care Immediately Following Birth in Labor & Delivery ................................................. 2
Thermoregulation in the Newborn Immediately after Birth .......................................................... 5
Emergency Oxygen Therapy for Newborns in Newborn Nursery ................................................ 7
C. Protocol ...................................................................................................................................... 8
Newborn Care ............................................................................................................................ 8
Hypoglycemia in the Newborn .................................................................................................. 15
Phototherapy ............................................................................................................................ 22
Newborn Circumcision Care ..................................................................................................... 26
Safe Sleep.26
IV.
References ......................................................................................................................... 32
V. Reviewed/Approved by .................................................................................................................. 33
VI. Original Policy Date and Revisions ................................................................................................ 33
II. Rationale
After birth, a neonate must quickly adapt to extrauterine life, even though many of the neonates
body systems are still developing. During this time of adaptation, the nurse must be aware of
normal neonatal physiologic characteristics and assessment findings in order to detect possible
problems and initiate appropriate interventions.
III. Policy/Procedure
A. Policy
Describes practice utilizing current evidence and clinical guidelines for nursing care as it relates
to managing the normal newborn infant after birth and during hospitalization
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Date this Version Effective: Dec 2015
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B. Procedure
Neopuff set
Laryngoscope
Stylettes
Neonatal Code Cart (carts located outside triage 1 and between ORs 2 & 3)
identification bands
Disposable gloves
Warm blanket
Infant hat
Thermometer
Vitamin K
This practice based on intimate contact within the first hours of life may
facilitate maternal-infant behavior and interactions through sensory stimuli
such as touch, warmth, and odor. Moreover, skin-to-skin contact and
rooming-in are considered critical components for successful breastfeeding
initiation and continuation, but are recommended for all couplets regardless
of feeding method. If skin-to-skin is interrupted for contraindication, it should
be re-introduced as soon as possible.
5. Dry infant, initiate mother/infant skin-to-skin, cover head with hat and cover baby with warm
blankets. Infants loose excessive heat via convection.
6. Assess immediately after birth:
Patency of airway
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Respiratory effort
8. Assess infant continuously for signs of respiratory distress such as grunting, nasal flaring,
chest retractions and cyanosis. Document vital signs every 30 minutes or more frequent as
indicated in the electronic medical record.
9. Take axillary temperature of infant and assess infant for signs of cold stress. Infant
temperature should be 36.4C. If cold stress was not prevented using skin-to-skin, and
infant exhibits signs of cold stress, transport to the NBN is necessary. Hypoxia, acidosis,
hypoglycemia, lethargy and pulmonary vasoconstriction indicate cold stress. For serious
complications contact NCCC immediately.
10. Evaluate thermoregulatory environment. (See the Thermoregulation in the Newborn
Immediately after Birth procedure below).
11. Assess infant for signs of hypoglycemia such as jitteriness and lethargy. (See the
Hypoglycemia in the Newborn protocol below). Symptomatic neonates need to be evaluated
by NCCC.
12. Identify infant:
Explain the procedure for checking identification bands with mother and or support
person.
13. Verify cord clamp 2.5cm from umbilicus and cut cord above the clamp. The cord clamp is
usually placed by the delivering LIP.
14. Assess the proximity of the cord clamp in relation to the skin around the umbilicus to prevent
injury of the infant.
15. Offer support person the opportunity to cut the cord if the infants condition warrants.
16. Weigh infant after 90 mins of life (unless medically necessary)
17. Encourage mother/infant contact and point out infant feeding cues.
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18. Encourage mother to initiate breastfeeding at the earliest signs of hunger. (See the protocol
in the UNC Hospitals Nursing Breastfeeding and Human Milk Storage and Handling policy).
Key Point:
Mother-baby couplets are likely to initiate breastfeeding within the first hour of
life if left skin-to-skin, uninterrupted. This is the time for encouragement and
more rudimentary guidance including feeding cues and general expectations
for feeding.
19. Transport infant to the Maternity Care Center within 2 hours of birth or immediately if signs
of any of the following occur:
Hypothermia (<36.4)
Respiratory distress
If infant is not transferred to Maternity Care Center within 2 hours, document a complete
head to toe assessment in the electronic medical record.
Key Point:
Time of birth
Method of feeding
Type of delivery
Anomalies
Complications
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24. a complete delivery summary form in the electronic medical record and infant MAR.
Vital Signs
Note: This task is to be performed by the RN or LPN.
Per Unit Protocol is defined as
Assess temperature, heart rate and respirations at 30 mins of life and every 30
mins x4. If stable infant may have vital signs obtained once per shift unless
Late Preterm Infants (34 to 36 6/7 weeks gestation) receive vital signs every 4 hours.
CODE SEPSIS- Infants with a blood culture pending receive vital signs every 4 hours
until culture is documented as negative after 48hrs.
Note: If axillary temp greater than 37.5C or less than 36.4C, obtain rectal temperature; If rectal temperature is
less than 36.4C then warm baby using radiant warmer or skin-to-skin with mom and repeat rectal temp within 30
minutes;.
Preterm infants
Infection
Dehydration
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Hypoglycemic infants
Congenital hypothyroidism
1. Gather equipment:
Radiant warmer
Skin probe
Warm blankets/towels
Thermometer
Hat
2. Prior to delivery, increase temperature in labor room/recovery room to 75F. This prevents
heat loss due to convection.
3. Pre-warm radiant warmer. This prevents heat loss due to conduction.
4. Place warm blankets/towels under radiant warmer element. This prevents conductive heat
loss in the case that the mother or other support person is not available for skin-to-skin
contact.
5. Place infant skin-to-skin with mother and warm blankets over mother and baby. Skin-to-skin
contact is the best heat source, but both will provide a heat giving environment.
6. Dry infant with warm absorbent blankets and/or towels, and immediately replace used
blankets and/or towels with new warm ones. This prevents evaporative heat loss.
7. Warm hands and stethoscopes before coming in contact with infant. This prevents heat loss
due to conduction.
8. Keep infant away from air conditioning ducts and other drafts. This prevents heat loss from
convection and evaporation.
9. Keep oxygen (if used) directly over infants nose and mouth. This prevents heat loss from
convection and evaporation.
10. Place a hat on the infants head and change when wet or soiled. This prevents heat loss
from evaporation.
11. Maintain the infants temperature 36.4 C to 37.5 C while with mother in Labor &
Delivery.
Key Point:
Place infant next to mothers skin with warm blankets covering them. If cold
stress ensues, use a portable radiant warmer and set skin temperature probe
for 36.7 C to slowly warm infant.
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12. Assess infant for signs of hyperthermia. Usually hyperthermic infants are warm to touch and
exhibit red skin due to vasodilation related to releasing excess heat. Sweating is generally
not present in infants
Key Point:
13. Assess infants temperature, per axilla, with electronic thermometer every 30 minutes for the
first 2 hours after birth for a total of 4 times.
14. Transfer infant to nursery and report to care provider on thermoregulatory status if it is not
possible to maintain infants temperature at 36.4 C. Consider obtaining a blood glucose
level if thermoregulation is compromised.
a. Instructions noted in order set: Place under radiant warmer until temperature is >36.7 C.
Remove infant from warmer. Double swaddle or place skin to skin again. Recheck
temperature in 30 mins. If temperature drops again below 36.4 place under warmer for
2nd time and notify LIP. Obtain blood glucose if radiant warmer needed second time.
15. Document infants temperature and nursing actions on appropriate electronic medical
record.
O2 flow meter
Tubing
Neopuff set
2. Assure that the infant is not choking, which is the primary cause of cyanosis.
3. Clear the airway with a bulb syringe if obstructed by mucous in the infants mouth. Stroke
babys back. For excessive mucous in the throat, wall suction may be used.
4. Position the infant on back with the head of crib elevated and neck slightly extended. A
rolled pillowcase may be placed under the back of shoulders to accommodate the
extension.
5. Place the infant on continuous pulse oximetry. (This is a rapid and non-invasive assessment
of the infants oxygenation)
6. Place the facemask securely over the infants nose and mouth and turn O2 source to 8L/min.
and provide blow by oxygen. No longer than 15 minutes.
7. If the mask is held to tightly, pressure will build up in the Neopuff device and be transmitted
to the infants lungs in the form on CPAP or PEEP.
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C. Protocol
Newborn Care
Term newborn infants (37-42 weeks gestation) progress through predictable stages of
adjustment to extrauterine life. Key elements of concern are:
airway patency
oxygenation
ventilation
thermoregulation
any abnormalities
family attachment
feeding
excreting bilirubin.
Providing family-centered care, with minimal separation of mother and infant, fosters motherinfant attachment and early assumption of the parent role, as well as the parents understanding
of their babys unique needs. Early feeding of this patient population is mutually beneficial to
the mother and infant. It stabilizes blood glucose and stimulates stooling of the infant and
promotes maternal infant bonding. Breastfeeding enhances these benefits by providing nutrition,
which is rich in infection-fighting properties, including immunoglobulins. Breastfeeding also
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promotes skin-to-skin contact with the mother that facilitates temperature regulation of the
infant.
1. Resources
NCCC nurses
Lactation Consultants
2. Assessment
cry
weight
Moro reflex
fontanels
trauma
output
review of systems
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Assess pulse oximetry if indicated by infants respiratory status. (Refer to the protocol in
the UNC Hospitals Pediatric Cardiorespiratory and Pulse Oximetry Monitoring policy)
Assess Bilirubin:
Please check a transcutaneous bilirubin (TCB) on all babies after 24 hours of life
with batched screening using the handheld bilimeter.
Use Bilitool.org to evaluate risk zone for infant. If HIGH RISK ZONE RN to draw neobili STAT
(may be drawn with newborn screen if lab available.) Notify LIP with results. Otherwise-if
TCB>7mg/dL RN to order neobili with newborn screen
www.bilitool.org
Note: Refer to Bhutani curve to identify light level for phototherapy treatment based on
results of neobili and risk level.
Risk factors include: <37 weeks gestation, hemolytic disease, asphyxia, lethargy, temperature
instability, sepsis, acidosis, albumin <3.0g/dL
3. Notify LIP
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edema, physical abnormalities or birth trauma, e.g. palsy, bone crepitations, facial palsy
maternal risk factors requiring immediate follow-up (e.g. increased maternal temperature
at delivery)
problems with parents caregiver bonding or providing routine care to the infant
4. Administration
Verify Erythromycin Ophthalmic Ointment given within 1 hour of birth (usually in Labor
and Delivery).
5. Nursing Care
Weigh daily
Wear gloves during all contact with infant prior to initial bath and all mothers body fluids
are removed.
Offer Bath and scalp care only when temperature 36.7C after 24 hours
i.
Exception- Infants born to mothers with active HSV lesions or are HIV positive
should be bathed shortly after birth.
Delay bath/scalp care until the infants temperature has been stabilized at
36.7C (term infants) 36.7 or higher for > 4 hours (near term infants) and
after 24 hours of life.
Place infant skin-to-skin or under warmer if temperature < 36.4C after bath until
temperature reaches at least 36.7C.
Dress infant in shirt and diaper and swaddle in 2 blankets with cap when temperature
stabilizes at 36.7 C. Recheck temperature in 30 mins to ensure thermoregulation has
been accomplished.
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Assist mother with breastfeeding (or provide non-breastfed infants with formula) every 24 hours after the initial feeding.
Note: Breastfed infants are not to receive supplemental formula feedings unless
requested by the mother or ordered by the LIP. Before supplementation is given,
provide mother with supplementation information sheet which should be
reviewed verbally with patient to ensure adequate understanding of risks of
formula supplementation and attend to mothers desire for supplementation. As
with all patient information, qualified interpreters must be utilized to ensure
informed understanding. Review safe Baby Feeding and Diaper Count Chart
Supplementation (Mixed Feeding) - Yellow Sheet
Observe for signs of milk transfer during a minimum of two feedings prior to discharge.
Signs of milk transfer include suck-swallow-breath cycle and satisfaction at the end of
feeding.
Check diaper before and after feedings and when infant cries.
Replace cord clamp if oozing occurs or end of cord is not clearly visible past outer edge
of clamp.
Suction with bulb syringe for excessive fluid/mucus in nose, mouth, or throat.
Provide support for family when abnormalities found or if infant transferred to NCCC.
Activate order for serum bilirubin if TCB >12mg/dL (as described in this protocol under
the transcutaneous bilirubin screening guidelines) by ordering a NEW Serum Neobili Do
not use the nursing order for prn neobili as it does NOT communicate with the lab
computer system.
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Obtain an order for newborn metabolic screening & newborn hearing screen prior to
hospital discharge.
Obtain an order for a Rh incompatibility work up and send cord blood or capillary blood
specimen for:
Obtain an order for urine and meconium for toxicology on all infants admitted in the first
48 hrs. of life who have any of the following risk factors:
Maternal Risk Factors
history of substance abuse
a) poor prenatal care (prenatal care starting after 16 weeks gestation or less
than 4 prenatal visits)
b) history of child abuse, neglect or court ordered placement of children
outside of the home
c) history of domestic violence
d) history of hepatitis, HIV, syphilis or prostitution
e) unexplained placental abruption
f)
Obtain an order for blood culture and CBC w/differential if mother is:
is GBS unknown and rupture of membranes occurred > 18 hours prior to delivery
6. Safety
Check identification of infant on admission, prior to visit to mother, before any procedure,
and at discharge.
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The identification bands are to remain intact on the mother and infant. These bands
are left in place to signify that the couplet belong together and not as a patient
identifier.
For mother/baby couplets: At time of discharge assure both patients ID bands are
removed to de-identify them as patients.
Give the patient/family a discharge pass (preferably the mother). Inform the person
providing transportation to wait to get the car until the patient is in the lobby.
The discharge pass identifies the patient as discharged and can be obtained from
the nurses station. Pediatric patients do not require a discharge pass as they should
be accompanied by a responsible adult. The HUGS tag must be removed with the
patient ID band.
Provide infant car seat safety screening prior to discharge of infants born <37 weeks
gestation, < 5 LBS (2.23 kg) or with any congenital issue that may compromise airway.
Refer to the procedure in the UNC Hospitals Nursing Car Seat: Screening and ordering
policy.
7. Emergency Measures
Choking:
i)
j)
comparison of indent-a-bands
feeding
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diapering
9. Documentation
assessment findings
reported conditions
Early and exclusive breastfeeding best meets the nutritional needs of healthy term
neonates and is protective against hypoglycemia. Healthy, term newborns that are
breastfed on-demand need neither supplementation nor routine monitoring of blood
glucose levels. Exclusively breastfed healthy neonates, in general, tend to have and
safely tolerate lower blood glucose concentrations, but higher concentration of ketones,
than formula-fed infants. This is thought to be a protective physiologic mechanism since
exclusively breastfed newborns also have the most effective counter-regulatory release
of glucose by the liver. Healthy, term newborns do not develop symptomatic
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Immediate consult from NCCC team for all symptomatic infants or at risk infants not
responding to feedings
2. Assess for:
WARNING:
General findings:
a) abnormal or high-pitched cry
b) persistent hypothermia
c) temperature instability
d) diaphoresis
e) weak or no suck
f) poor feeding ability
Neurological:
a) irritability
b) tremors or jitteriness not resolved by suckling on gloved finger
c) exaggerated Moro reflex
d) lethargy
e) hypotonia
f) seizures
g) abnormal eye movements
Cardiorespiratory:
a) tachypnea
b) apnea
c) cyanosis
d) respiratory distress
e) tachycardia
b. at-risk newborns for which routine monitoring of heel stick glucose is always indicated,
even if asymptomatic.
Neonatal-dependent factors:
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Maternal-dependent factors:
c. at risk newborns for which monitoring of heel stick glucose may be indicated based
upon assessment findings, the presence of multiple risk factors simultaneously, or LIP
order, even if asymptomatic.
Neonatal-dependent factors:
Hypoxia-ischemia
Sepsis
Respiratory distress
Maternal-dependent factors:
3. Notify LIP
For all newborns where notification of the LIP is indicated on the hypoglycemia algorithm
4. Nursing Care
Reduce cold stress by drying and placing all healthy term newborns skin-to-skin
immediately following birth and throughout hospital stay for physiologic
thermoregulation. Begin/continue breastfeeding as described in the algorithm, assisting
the mother with latch and positioning. Page lactation services for immediate assistance
for consultation, if warranted.
If first screening heel stick glucose concentration is below threshold level: Supplement
with 3-5 mL/kg/feeding of expressed colostrum or breast milk, donor human milk, or
substitute formula. Cup or spoon-feeding is preferred over bottle feeding. D5W and
D10W are not acceptable supplements.
o
Newborn should remain skin-to-skin with mother whenever possible, even if being
supplemented. If separation is unavoidable, place infant under radiant warmer.
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Obtain heel stick glucose on all symptomatic newborns and notify the LIP Stat for
infants whose heel stick glucose levels are 40 mg/dL.
Note: The recommended treatment in this situation is IV glucose. Oral feedings
and skin-to-skin contact typically may continue during IV glucose therapy
and mothers should be encouraged to breastfeed their babies. Mothers
should begin expressing their milk as soon as possible if not directly
nursing infant or if infant is not latching well. Obtain lactation consultation
for all breastfeeding newborns transferred to NCCC.
Initiate feeding within one hour of life and obtain heel stick glucose at 90
minutes of life regardless of if the infant has fed. Warm the heel with a heel
warmer prior to obtaining blood specimen.
o
Initial heel stick glucose is 41 mg/dL may feed the infant every 2-3
hours and check BG prior to each feed.
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Date this Version Effective: Feb 2016
o
If the heel stick blood glucose is < 35 mg/dL feed infant measurable
amount and notify NBN LIP
If the heel stick blood glucose is > 46 mg/dL may feed the infant
every 2-3 hours and check BG prior to each feed
Evaluate all infants carefully who demonstrate any of the following signs
and/or symptoms:
o
Intolerance of feedings
Heel stick glucose concentration that does not increase after a feeding
Evaluate heel stick sites every shift for skin breakdown and/or signs of
infection and provide wound care when appropriate.
5. Safety
Any infant that becomes symptomatic at any point during the implementation of the
algorithm needs to be evaluated by a LIP in the NBN or NCCC immediately.
Notify NBN LIP if infant has not passed protocol by 12 hours of life.
Per algorithm except for LIP or RN requested spot checks based on clinical judgment
once monitoring of the heel stick glucose is initiated, three consecutive screenings 46
mg/dL must be obtained prior to discontinuing BG checks.
If BG values during birth-4hrs of life are 41 they may be included in the 3 consecutive
passing values. Heel stick values are a screening tool, and may be confirmed by a
formal laboratory plasma glucose value for formal diagnosis.
6. Patient/Caregiver Teaching
Discuss causes and symptoms of hypoglycemia. Instruct parents to notify nursing staff if
newborn does not actively suck during feedings or demonstrates other symptoms of
hypoglycemia.
Emphasize importance of skin-to-skin contact and frequent feedings for achieving and
maintaining stable blood glucose levels of hypoglycemic newborns.
Note: Inform parents that oral feedings and skin-to-skin contact usually may continue
during IV glucose therapy if infant is transferred to NCCC.
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possible if infant is not latching well or is transferred to NCCC. Provide lactation contact
information.
7. Documentation
Assessment findings
Reported conditions
Feeding attempts
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Phototherapy
Altered metabolism of bilirubin is a common problem during the first week after birth. Excessive
bilirubin production or altered hepatic clearance of bilirubin can lead to hyperbilirubinemia, a
condition associated with kernicterus, especially in preterm and sick newborns. Common
causes of hyperbilirubinemia include: fetomaternal blood group incompatibilities; congenital
enzyme deficiencies; extensive bruising or cephalohematoma; sepsis; polycythemia; delayed
passage of meconium; and altered hepatic function. Hyperbilirubinemia should be suspected in
the following situations: onset of jaundice within 24 hours after birth; persistent jaundice (greater
than one week in the term infant, greater than two weeks in the preterm infant); or a rise in total
bilirubin of greater than 5 mg/dl per day. Phototherapy oxidizes bilirubin into water-soluble
components for excretion and can be given via, Bili-lights (neoBLUE LED Phototherapy
light), traditional bank lights, BiliBed, or Bili-blanket .
Note: Severe neonatal hyperbilirubinemia (> 30mg/dL) is considered a sentinel event and
should be reported to Risk Management.
1. Assessment
Assess every 4 hours:
skin, sclera, and mucous membrane color, i.e. bronzing and jaundice
axillary temperature (normal: 36.4C- 37.5 C) Obtain rectal temperature if outside these
parameters
level of consciousness and activity, e.g. irritability, jitteriness, lethargy, seizure activity
2. Notify LIP
abnormal temperature
feeding problems, i.e. weak suck, inability to ingest and retain adequate fluids
lethargy
seizure activity
respiratory distress
3. Nursing Care
a. Obtain an order to monitor results of:
initial blood typing (mother and newborn) and direct and indirect Coombs
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Hct/Hgb and/or CBC with differential if ABO incompatible with positive COOMBS
b. If phototherapy is ordered via Bili-lights (neoBLUE or traditional bank lights) follow the
steps/notes below:
Note: For neoBLUE LED Phototherapy, a setting of high corresponds with intensive
phototherapy traditionally known as double or triple phototherapy. A setting of
low corresponds to conventional phototherapy traditionally known as single
phototherapy.
Phototherapy can be provided in the mother's room. This is optimal to promote nonseparation of mother and infant.
Undress infant completely (except for diaper) while maintaining a neutral thermal
environment with a radiant heat source.
Encourage parents to care for infant during feedings (30-45 minutes when formulafeeding or up to one hour when breastfeeding) unless contraindicated.
Secure the Bili-Combi (and the infant) to the bed with the Velcro strips.
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May leave eyes uncovered when Bili-blanket is used alone unless infant is premature
or undressed, eyes must be covered.
Turn Bili-blanket off while giving care (Bili-blanket may remain on when holding
/feeding infant).
g. Obtain an order to administer glycerin chip per rectum if no stool for 24 hours.
4. Safety
a. Cover eyes continuously when infant is under Bili-lights.
b. Do not apply lotions, creams, or oils to infants receiving phototherapy in order to prevent
burns.
c. Use principles of each light source for combined therapy.
5. Parent/Caregiver Teaching
a. Depending on the situation, the nurse may instruct caregivers and/or reinforce the
importance of treatment, length of treatment, lab tests, and sufficient fluid.
b. Instruct parents to keep infant's eyes covered during phototherapy unless using a Biliblanket only.
c. Emphasize length of time infant may be out from under Bili-lights (no longer than 45
minutes).
d. Instruct parents/caregiver to inform nurse of intake and output.
e. Instruct parents/caregiver to notify infant's nurse if infant refuses feeding or displays
change in activity level, e.g. twitching, tremors, lethargy.
6. Documentation
additional interventions
assessment findings
reported conditions
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Bilirubin:
Figure 2
Please check a transcutaneous bilirubin (TCB) on all babies after 24 hours of life with batched screening. If TCB
>7, RN to order neobili with newborn screen.
Use Bilitool.org to evaluate risk zone for infant. If HIGH RISK ZONE RN to draw neobili STAT (may be drawn with
newborn screen if lab available.) Notify LIP with results. www.bilitool.org
Late preterm infants will continue to have serum bili done at 24 hours with newborn screen.
Obtain TCB daily on any infant <37 weeks gestation. After first 24 hours of age, draw and send neonatal
bilirubin if subsequent TCB > 12.
Note: Refer to bilitool.org to assess light level for phototherapy treatment based on results of neobili
and risk level per AAP guideline.
Risk factors include: <37 weeks gestation, hemolytic disease, asphyxia, lethargy, temperature instability,
sepsis, acidosis, albumin <3.0g/dL
Nursing Care
Activate order for serum bilirubin if TCB is as described in this protocol under the transcutaneous
bilirubin screening guidelines by ordering a NEW Serum Neobili Order- nursing cannot use the
nursing order for prn neobili as it does NOT communicate with the lab computer system.
Risk Zone
Light Level
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q 15 minutes x 2 or
q 30 minutes x 3 then
q 4 hours x 24 hours
d. Assess for signs of infection q shift or with every Vaseline gauze dressing change or
diaper change.
e. Monitor occurrence of voids.
2. Notify LIP
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3. Nursing Care
a. Withhold feedings a minimum of one hour prior to procedure.
b. Maintain thermo-neutral environment to prevent cold stress.
c. Obtain an order to apply topical anesthetic cream to the foreskin in the area of the
incision and to the penile block site one hour prior to the procedure.
d. Offer infant pacifier dipped in 24% sucrose 2 minutes prior to and during procedure.
Note: 24% sucrose may be administered via syringe (0.1-0.2mL) to breastfed baby
e. Obtain an order to maintain thermo-neutral environment to prevent cold stress.
f.
Ensure that all required equipment is at the bedside for the penile block and
circumcision.
j.
Set timer for 5 minutes to designate wait period between administration of penile block
and procedure.
k. Remove infant from board immediately after procedure, rewrap, and return to
crib/isolette for 15 minutes of nursing observation in the newborn nursery.
l.
Cleanse circumcision site during the first 24 hours only when gauze is soiled by stool:
m. Cleanse site after 24 hours with non-alkaline soap and water with each diaper change
until site is healed.
n. Change the Vaseline gauze within the first 24 hours if the dressing becomes soiled with
stool.
o. Obtain an order to apply Gelfoam to site for bleeding.
4. Safety
Check immediately prior to procedure that:
Obtain an order to discharge after circumcision if circumcision site has not bled for one
hour
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5. Patient/Caregiver Teaching
a. Instruct the mother/caregiver that infant discomfort and anesthetic may interrupt
breastfeeding.
b. Give mother/caregiver UNC Healthcare teaching booklet Caring for Yourself and Your
Baby and one-page patient education guide Circumcision: A Choice (available in
Spanish and English).
c. Instruct mother/caregiver to observe site every 15 minutes for bleeding during first hour
post-procedure or more often if excessive bleeding has occurred.
d. Instruct mother/caregiver to report any of the following:
e. Demonstrate to parent(s)/caregiver:
6. Documentation
time block administered and the time procedure begins and ends
assessment findings
reported conditions
Care of the Newborn using Safe Sleep Guidelines for Newborn Nursery
1. Assessment
Place infants on their backs to sleep for every sleep in the infants bassinet
3. Nursing Care
Place infants on their backs to sleep for every sleep in the infants bassinet
Place Infant on a firm sleep surface such as a crib mattress covered with a fitted
sheet.
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a) The infants crib or other sleeping device should be placed in the parents
bedroom close to the parents bed.
b) Infants may be brought into the bed for feeding or comforting but should be
returned to their own crib when the parent is ready to return to sleep.
c) Infants should not be fed on a couch or armchair when there is a high risk that
the parent might fall asleep.
4. Patient/caregiver teaching
All Health care professionals, caring for Newborn infants should endorse safe sleep
recommendations from birth.
5. Caregiver Education
a. See Figure 3
6. Documentation
Document completed safe sleep teaching in the infants electronic medical record.
Figure 3
Rationale
Comments
Sleeping Position:
Place infants on their backs to sleep a.
for every sleep. Have parents
communicate this back to sleep
message with everyone who cares for
their infant.
Avoid overheating.
Do not cover the infants face or head.
Infants should be dressed in no more
than 1 layer more than an adult would
wear to be comfortable in that
environment.
Supervised, awake tummy time is
recommended to facilitate
development and to minimize
development of positional
plagiocephaly.
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There is insufficient
evidence to recommend
use of a fan.
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Smoking/Smoke
Clothing exposed to secondhand
smoke should be changed, or a cover
gown provided, prior to handling
infants.
Wash hands after smoking and before
touching infant.
Encourage families to set strict rules
for smoke-free homes and cars to
eliminate secondhand smoke.
Feeding and Positioning
Breast feeding is recommended
Infants may be brought into bed for
feeding or comforting but should be
returned to their own bed when the
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IV. References
Alden, K. (2011). Physiologic and behavioral adaptations of the newborn. In Lowdermilk, D. &
Perry, S.(Editors) Maternity & Womens Health Care (10th ed.) (pp. 639-641). St. Louis:
Mosby/Elsevier.
American Academy of Pediatrics (2012). Male Circumcision. Pediatrics, 130(3). P. 756-785.
American Academy of Pediatrics (2011). Postnatal glucose homeostasis in late-preterm and term
infants. 127(3). p. 575-579
American Academy of Pediatrics Policy Statement: SIDS and other Sleep- Related Infant Deaths:
Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011;128;1030
American Academy of Pediatrics, Task Force of Sudden Infant Death Syndrome. (2011). SIDS and
Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping
Environment. Pediatrics, 128(5), 1030-1039.
American Academy of Pediatrics Technical Report: SIDS and other Sleep-Related Infant Deaths:
Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011; 128;
e1341
Baddock SA, Galland BC, Bolton DP, Williams SM and Taylor BJ. (2012). Hypoxic and Hypercapnic
Events in Young Infants During Bed-Sharing. Pediatrics, 130, 237-244
Becher, Bhushan & Lyon: Unexpected Collapse in Apparently Health Newborns-a Prospective
National Study of a Missing Cohort of Neonatal Deaths and Near-Death Events, ADC Fetal and
Neonatal Edition(2012). 97; F30-F34.
Helsley L, McDonald JV and Stewart VT. (2010) Addressing In-Hospital Falls of Newborn Infants.
The Joint Commission Journal on Quality and Patient Safety, 36(7), 327-333
Lowdermilk, D.L., & Perry, S.E. (2011). Maternity & Womens Health Care. (10th ed.). St Louis:
Mosby.
Merenstein G and Gardner S(2011) Handbook of Neonatal Intensive Care (7th ed). Maryland
Heights MO: CV Mosby/Elsevier
Moon RY, Oden RP, Joyner BL and Ajao TI.(2010) Qualitative Analysis of Beliefs and Perceptions
about Sudden Infant Death Syndrome in African American Mothers: Implications for Safe Sleep
Recommendations. Journal of Pediatrics, 157, 92-7
National Association of Neonatal Nurses position statement on co-bedding of twins and higherorder multiples. Retrieved 2/3/13 from
http://www.nann.org/uploads/files/Cobedding_of_Twins_or_Higher-Order_Multiples_2011.PDF
neoBLUE LED Phototherapy. Hospital Inservice. http://www.natus.com/documents/051693E.pdf
Schnitzer PG, Covington TM and Dykstra HK.(2012) Sudden Unexpected Infant Deaths: Sleep
Environment and Circumstances. American Journal of Obstetrics, Gynecologic and Neonatal
Nursing, 39, 618-626
Trachtenberg FL, Haas EA, Kinney HC, Stanley C and Krous HF.(2012) Risk Factor Changes for
Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign Pediatrics, 129,630-638
Vennemann MM, Hense HW, Bajanowski T, Blair PS, Complojer C, Moon RY, and KiechlKohlendorfer U.(2012) Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We
Resolve the Debate? Journal of Pediatrics, 160,44-48
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Verklan MT and Walden M (2010). Core Curriculum of Neonatal Intensive Care Nursing (4th ed).
Philadelphia PA:Saunders.
V. Reviewed/Approved by
Nursing Policy Committee, Womens CPG, UNC Pediatrics
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