1. Welcome to the Newborn Nursery Erin Burnette, NP-C Emily Freeman, CPNP Jamie Haushalter, CPNP

2. Student 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. Basics Standard of care is “rooming in” Try to minimize disruptions to maternal-infant bonding Encourage and promote breastfeeding

4. SETTING New Born Parents: Happy Crisis Guilt of Parenting Fear of Imperfection Vulnerability/Imprintability Hyper-vigilance of Parent Receptors "Happy Crisis" by W. Brown

5. SETTING 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 Be a continual learner : – Temporal Science of Medicine – Observer, Listener, Modeling "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 Clearly Identify Self Know the Players in the Room "Happy Crisis" by W. Brown

7. PRESENTATION Establish your Comfort Zone: – Physically / Verbally – Starting the Conversation – Style of Interaction: Re-enforce the Infant’s Name, etc Positive normal findings You may have noticed [normal to you, but concern of the parent] "Happy Crisis" by W. Brown

8. 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

9. Review Newborn Orientation Guide Gestational age growth curve Bili curve/Bilitool.com GBS protocol Hypoglycemia protocol Drug screening protocol

10. 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”) –TCBs are not 100% accurate, must use clinical judgement

11. Neonatal Jaunidice All newborns will also have a repeat TCB prior to discharge. –Neobili will be automatically ordered by nursing if TCB ≥ 12. Should consider neobili if TCB >10.

12. Hyperbilirubinemia

13. Risk for hyperbili www.bilitool.org

14. 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.

15. Algorithm Pulse Ox on Right Hand (RH) and One Foot After 18 Hours of Age

16. Hypoglycemia Protocol Late Preterm: 34-36 6/7 weeks SGA: <2500g LGA: >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.

17. Hypoglycemia Protocol Goal is 3 consecutive blood glucose levels >40 from birth-4hrs or >45 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.

19. 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 3-5 days after delivery

20. Maternal-Infant Bonding Infant should be in room with mother at all times Encourage skin-to-skin time Respect Quiet Time (2-4pm) unless urgent If your schedule allows, offer to come back to examine the baby if mom is nursing or has visitors present

21. 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

22. The Board You will find: – Babies name, room # – Service (UNC vs FP vs PHS, etc) – Completion of Hep B, hearing test, NBN screen, circ…. – Other information such as SW consult, etc.

23. NBN Cards Gather information on admission from: – Moms chart: webcis for labs, H&P, ultrasound reports, etc; echart (L&D summary) – 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

24. Don’t hesitate to ask questions!