NMCP Maternal Newborn Nursing Orientation Information Packet

Denise Devonshire MSN-Ed, RN | Orientation Information |
Naval Medical Center
Portsmouth
MATERNAL/NEWBORN NURSING

Welcome to NMCP Inpatient Maternal InfantUnit
Welcome aboard to the Inpatient Maternal Infant unit. The postpartum unit is also known as 4KL.
This department is a two ward department with 49 beds. Here you will receive some of the best
training in the Navy. You have the opportunity to care for our Active Duty, Dependent Wife, and
Dependent Daughters of the U.S. Armed Forces and NATO Joint Force dependents.
You have been chosen to care for this special population. You work at a Level 3 Military Facility
which cares for women and babies from 24 weeks Estimated Gestational Age and up who are
normal/routine to severely compromised health statuses. On the postpartum unit you will be
caring for stable newborns and mothers who did or did not experience complications throughout
their pregnancy or labor and delivery.
The purpose of this orientation information packet is to familiarize yourself with some basic
maternal/newborn nursing that is very pertinent in your job here at NMCP. Your fellow RN’s and
Corpsman are here to help you train to care for this special population. Please do not be afraid to
ask questions. There are no stupid questions. It is better to question than to execute a procedure or
medication that could result in devastating consequences.
Each section of this booklet with have an examination that you will need to turn in to your Clinical
Nurse Educator.

Maternal PostPartum Nursing
Let’s get back to basics to understand why we do the thingswe do with our patient’s and what we
are looking for in our assessments.
Pregnancy
At the time of ovulation the endometrial lining of the uterus is lined with rich nutrients. The
endometrial lining is ready to begin nourishing a zygote (fertilized egg). If the ovum (unfertilized
egg) is not fertilized the nutrient rich endometrial lining is shed in what we know as the woman’s
period. If fertilization occurs the ovum becomes a zygote and travels down the fallopian tube
(where fertilization occurs in the outer third of the tube) into the uterus. Remember, the uterine
lining (endometrial) is rich with nutrients where the zygote implants and receives this vital
nutrients to survive. Once implantation occurs this is where the chorionic villi start to supply the
zygote with nutrients and waste removal. Think of this as connecting two hoses together. Water
rushes freely in the hose.
As pregnancy ensues the uterus becomes engorged with a large blood supply. The uterus now has
to supply oxygen, nutrients, and waste removal for the growing baby in its cavity. When conception
occurs the mothers blood supply increases by 50 % to help oxygenate the uterus and fetus. Our
bodies understand there will be a delivery 10 months from conception. The increase in blood supply
ensures the mother has enough blood to lose after delivery without becoming hemodynamically
unstable. This is an important factor to consider when caring for a postpartum mother. It is
important to know what her H & H and platelet levels were before delivery. Most women typically
have a hemoglobin level above 10.5 g/dl. It is when it falls below these levels the mother and
possibly baby can become anemic. Think of it this way:
This gas gauge represents a woman who is
hemodynamically stable. When conception occurs her
blood volume increases even more to compensate for
the blood loss that will occur at delivery.
This gas gauge represents a mother who is anemic or
starting very low. When she becomes pregnant her
blood volume increases. But, may not be enough to
compensate for delivery.
This
discussion
leads to why
we check for
bleeding
after delivery
Right now
you are
wondering
why we are
discussing
early
pregnancy

Babies have
between 125-150 ml
of blood in their
system at birth
When delivery occurs and the mother’s blood supply is over the full mark she can lose what her
body made extra and a little bit more if it occurs. The body tries to compensate for the blood loss
that will occur at delivery. Pretty cool huh?
With the increase in blood supply made by the bone marrow it is no wonder mothers become so
fatigued in early pregnancy. The RBC’s are working for two people (mom and baby). During the
pregnancy the uterus should stay soft and non-tender. This allows easy transfer of oxygen and
nutrients to flow between mother and baby. Any time the uterus contracts the amount of oxygen is
shunted in half until the contraction has ended and the flow of oxygen is again flowing freely to the
baby. This shunting of the blood supply during a contraction is a perfectly normal physiological
response. Most fetuses tolerate this action by the uterus.
Delivery
At the time of admission and before delivery if possible (precipitous deliveries) the 4M staff obtain
a CBC (complete blood count; includes H&H and platelets) and a Type and Screen. Initial labs are
drawn to determine the hemodynamic status of the mother. Will she need blood transfusion after
delivery? Will she be able to have an epidural? Why do you think these lab levels are important to
assess?
The mother will labor for an undetermined about of time and deliver her baby. Every pregnancy
and woman is different. No labor is the same. The estimated blood loss (EBL) is important to know
at this stage. Estimated blood loss is the close approximation of blood lost during delivery. Once
the baby is delivered and on mom’s abdomen the placenta remains in the uterine cavity to be
delivered. It can take up to 30 minutes for the placenta to detach from the uterine implantation
site. Most placenta’s deliver within 5-15 minutes after birth. The provider (OB or CNM) will inspect
the placenta to be sure it delivered in one piece. If the placenta detached and became fragmented
those parts of the placenta can be left behind in the uterus or vagina. This can lead to problems
immediately after delivery or have a delayed effect. A Pitocin infusion is given after delivery of the
baby to initiate the uterus to contract firmly to reduce the amount of blood being released from the
villi that was formed between the uterus and placenta. It is very important for those connectors to
be shut off so the amount of blood rushing through is minimal. If the uterine villi does not
constrict slowing the amount of blood coming through those vessels a woman can lose over half of
her blood supply in as littleas 5 minutes. (Remember, adults have 5 liters of blood in their body at
any given time)
Once the baby is delivered the OB nurse will rub the fundus (top of the uterus) to enhance the
uteruses ability to clamp down and slow the amount of bleeding. You have to remember that where
the placenta was once was, is now much like a scab that was ripped off. What happens when we do
that? It bleeds right? Same theory applies to the implantation site of the placenta. It is very
important to assess the firmness of the uterus, the station at which it is in relation to the umbilicus
and the amount of lochia (bleeding) coming from the vagina. The OB nurse will assess the uterus
every 15 minutes x4 (1 hour), every 30 x 2 (1 hour) and then every 4 hours or until transferred to PP
in which a new set of orders will be initiated.
Why do
you think?
What do
you think
it will tell
us?

Pregnancy Complications
Complications of pregnancy can occur at any time and in any woman. It may also occur in one
pregnancy, but not a subsequent pregnancy. Although, the likelihood of PIH and pre-eclampsia in
one pregnancy does increases the odds of reoccurrence in subsequent pregnancies. Some of the
most common pregnancy complications are Pregnancy Induced Hypertension (PIH), Gestational
Diabetes Mellitus (GDM), and Cholestasis of Pregnancy (Gall Bladder insufficiency).
PIH
Pregnancy Induced Hypertension (PIH) is a complication characterized by high blood pressure,
swelling due to fluid retention, and protein in the urine. It may also be called pre-eclampsia,
toxemia, or toxemia of pregnancy. Remember, blood pressure is the force of blood pushing against
blood vessel walls. The heart pumps blood into the arteries (blood vessels) that carry the blood
throughout the body. High blood pressure, also called hypertension, means that the pressure in the
arteries is above the normal range. The mother’s blood is already increased in amount to help
oxygenate the pregnancy. This places more demands on the circulatory system which in some
women increases the blood pressure.
Normal blood pressures are 120/80 mm Hg. Healthy women who have adequate BMI may have a
lower blood pressure and those women who gain a large amount of weight during their pregnancy
can increase their blood pressure. PIH pressures are any pressure 140/90 mm Hg. Symptoms
of high blood pressure are rapid or sudden weight gain, high blood pressure, protein in the urine,
and swelling (in the hands, feet, and face), abdominal pain, severe headaches, a change in reflexes,
spots before your eyes, reduced output of urine or no urine, blood in the urine, dizziness (feeling
clumsy or off balance), or excessive vomiting and nausea. Remember, some swelling is normal
during pregnancy.
Severe range blood pressures are 160/110 mm Hg. The patient may display a headache, lower
extremity swelling and hyper reflexes. BP ranges of this magnitude should be reported to the RN
and OB provider as soon as possible. Measurement of urine output is very important to note
because as the blood pressure rises the kidneys decrease in function. The kidneys control blood
pressure. This is why blood pressure rises. If the kidneys do not produce urine to excrete the “toxic”
waste then it backs up to the liver. The liver is the main metabolizer in the body. It metabolizes
everything the patient consumes, from medications to food. When toxins back up to the liver it
becomes sluggish and cannot function properly. This is the reason for the right sided rib pain. It is
just like a dam. The river flows smoothly until the dam can no longer keep the flow of water
moving. It then backs up and floods the land. This theory applies to the liver. Once it cannot work
properly the toxins start to back up into the brain. This is the reason for the headaches, visual
changes and hyper reflexes. It is very important to notify the provider if urine output is less than 50
ml’s per hour. The decrease in urine output can signify a worsening condition.
If severe range pressures are visible, PIH (green top and purple top with a urine specimen) labs will
need to be drawn, sent to lab and the provider notified ASAP. The patient may be moved to the
Labor Deck for a Magnesium Sulfate infusion. Magnesium Sulfate is not initially(bolus)
administered on the PP unit. There may be times when the Labor deck RN can come to 4KL to
administer the bolus administration of Magnesium Sulfate. The patient is then transferred to a
Corpsman
will not
care for pt’s
on Mag
sulfate

higher level of care and a PSR will need to be generated. (Anytime a patient is transferred to a
higher level of care a Patient Safety Report (PSR) is generated to enhance patient safety.)
When PIH worsens it leads to Pre-eclampsia Eclampsia DIC HELLP
Eclampsia is the condition where the patient sustains seizures because of the severe range blood
pressures (200’s/120 or ). Controlling the blood pressure is vital for both mother and fetal
survival. When a mother has a seizure there is a lack of oxygen from the mother to the uterus. The
baby does not receive oxygen during this time. The seizure can also cause a placental abruption
(the placenta is torn away from the wall of the uterus causing blood to form behind the placenta.
The baby’s oxygen access is now destroyed causing asphyxiation).
DIC (disseminated intervascular coagulation) is a systemic activation of blood coagulation, which
results in generation and deposition of fibrin, leading to microvascular thrombi in various organs
and contributing to multiple organ dysfunction syndrome (MODS). Consumption and subsequent
exhaustion of the coagulation proteins and platelets (from ongoing activation of coagulation) may
induce severe bleeding, though microclot formation may occur in the absence of severe clotting
factor depletion and bleeding. The patient will start to bleed from every orifice and “ooze” from IV
sites. The patient is moved to the ICU for closer monitoring and rapid blood administration.
HELLP syndrome is a life-threatening liver disorder thought to be a type of severe preeclampsia. It
is characterized by Hemolysis (destruction of red blood cells), Elevated Liver enzymes (which
indicate liver damage), and Low Platelet count.
HELLP is usually related to preeclampsia. About 10% to 20% of women who have severe
preeclampsia develop HELLP.1 In most cases, this happens before 35 weeks of pregnancy, though it
can also develop right after childbirth.
HELLP syndrome often occurs without warning and can be difficult to recognize. It can occur
without the signs of preeclampsia (which are usually a large increase in blood pressure and protein
in the urine). Symptoms of HELLP syndrome include: headache; vision problems; pain in the upper
right abdomen (liver); shoulder, neck, and other upper body pain (thispain also originates in the
liver); fatigue; nausea and vomiting; seizure.
HELLP syndrome can be life-threatening for both the mother and her fetus. A woman with
symptoms of HELLP syndrome requires emergency medical treatment. The patient would come to
4KL after she is stable in her condition.
GDM
Gestational Diabetes Mellitus (GDM) is a condition during pregnancy which the pancreas cannot
transport and use the glucose in an appropriate manner. Excess sugar that is not transported by the
pancreatic cells to the muscles is deposited in maternal fat and fetal cells. This greatly increases the
chances of a larger than gestational age (LGA) baby. When babies are receiving large amounts of
sugar the baby can become too big to be birthed vaginally (at risk for shoulder dystocia). The
mother will be counseled on a cesarean section.
At 28 weeks gestation the mother undergoes her glucose testing. She will be required to drink a
glucola drink and labs will be drawn to assess her pancreases ability to process the sugar in her
blood stream. Labs are taken before the test and at 1 hour after testing is obtained. If the 1 hour is
above the normal limits then a 2 hour and 3 hour lab will be drawn to assess how long her body

takes to process the sugar. The patient will be placed in a calorie restricted diet or on insulin and/or
metformin. Regular glucose monitoring will be initiated.
During labor the patient’s blood sugars will be monitored very carefully. A requirement for all
newborns delivered to moms who are GDM will be to assess their own glucose levels. 3 tests will be
done on labor and delivery and after each feeding on 4KL. It is important to notify the provider
when a BS is under the minimum of 40 because newborns will start to have respiratory distress and
decompensate very quickly. Educate your mom on notifying you on when they are going to feed.
Cholestasisof Pregnancy “Gall Bladder”
Cholestasis of pregnancy occurs in late pregnancy and triggers intense itching,usually on the hands
and feet but often on many other parts of the body. Cholestasis of pregnancy can make the mother
intensely uncomfortable but poses no long-term risk to an expectant mother. For a developing
baby, however, cholestasis of pregnancy can be dangerous. Doctors usually recommend early
delivery.
The term "cholestasis" refers to any condition that impairs the flow of bile — a digestive fluid —
from the liver. Bile is a digestive fluid produced in the liver that helps the digestive system break
down fats. It's possible that the increase in pregnancy hormones — such as occurs in the third
trimester — may slow the normal flow of bile out of the liver. Eventually, the buildup of bile in the
liver allows bile acids to enter the blood stream. Bile acids deposited in the mother's tissues can
lead to itching.Pregnancy is one of many possible causes of cholestasis. Other names for
cholestasis of pregnancy include obstetric cholestasis and intrahepatic cholestasis of pregnancy.
Intense itching is the predominant symptom of cholestasis of pregnancy. Most women feel itchy on
the palms of their hands or the soles of their feet, but some women feel itchy everywhere. The
itching is often worse at night and may be distressing enough that you can't sleep.
The itching is most common during the third trimester of pregnancy, but sometimes begins earlier.
It may feel worse as your due date approaches. Once your baby arrives, however, the itchiness
usually goes away within a few days. Other less common signs and symptoms of cholestasis of
pregnancy may include: yellowing of the skin and whites of the eyes (jaundice); nausea; loss of
appetite.
For mothers, cholestasis of pregnancy may temporarily affect the way the body absorbs fat-soluble
vitamins, but this rarely impacts overall nutrition. Itching usually resolves within a few days of
delivery, and subsequent liver problems are uncommon — although cholestasis is likely to recur
with other pregnancies.
For babies, the complications of cholestasis of pregnancy can be more severe. For reasons not well-
understood, cholestasis of pregnancy increases the risk of the baby being born too early (preterm
birth). It also increases the risk of meconium — the substance that accumulates in the baby's
intestines — getting into the amniotic fluid that surrounds the baby. If a baby inhales meconium
during delivery, he or she may have trouble breathing. There's also a risk of fetal death late in
pregnancy. Because of the potentially severe complications, your doctor may consider inducing
labor around the 37th week of pregnancy.
Normal vitals in Pregnancy
Maternal normal vitals in pregnancy are:

 Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg
 Breathing: 12 to 18 breaths per minute
 Pulse: 60 to 100 beats per minute
 Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C)/average 98.6°F (37°C)
POSTPARTUM ASSESSMENT
In postpartum, the patient is normally a well patient. Complications are possible, but for the most
part the patient is a healthy individual under temporary confinement expecting to take home a
healthy infant. The following are some guidelines to promote physiological psychological safety of
the postpartum patient.
ASSESSMENT: An assessment on any patient is always considered to be from head to toe. In the
postpartum patient, the assessment EXPANDS to also include the following (starting from top to
bottom):
BREASTS: Palpate each breast for firmness, fullness, tenderness, shininess, and contour. Does the
mom complain of sore nipples, are the nipples red, cracked or bleeding? Is she wearing a support
bra? Encourage all moms to wear a support bra whether nursing or non-nursing.
UTERUS: It is firm or is it boggy? The fundus should be firm; if not, gently massage to obtain
firmness and note if excess bleeding or clots are expelled during the massage. What is the fundal
height? It should decrease in height by one fingerbreadth below the umbilicus each day post
delivery. Nursing mothers may involute a little more quickly due to the release of oxytocin while
nursing. It is best to have the mother void and then have her lie flat in bed before checking fundal
height. If the fundus is above the uterus or displaced to the right or left, the mom may have a full
bladder or retained placenta fragments.
C-SECTION: If the patient had a C-Section, inspect the dressing or incision at this time noting site,
redness, discharge, and approximation of the incision if uncovered. Don't forget to check for bowel
sounds.
LOCHIA: When examining the fundus, check the lochia for color, amount, odor, and the number
of pads used. The first two to three days, lochia is bright red, similar to menses and is known as
RUBRA. The next few days lochia becomes serous and more watery and is known as SEROSA. By 10
to 14 days the lochia is thin and colorless and is known as ALBA. If the lochia has a foul odor, then
be suspicious of an infection. The doctor should be notified of any unusual odor, excessive
bleeding, or clotting.
EPISIOTOMY: Inspect the incision for REEDA. (If you do not know what this is, look it up in your
textbook before giving care) Also check for a hematoma. The patient may need to be medicated for
discomfort. Also check the rectum at this time for hemorrhoids and initiate appropriate measures if
uncomfortable to the patient.
ELIMINATION: BLADDER: Is mom voiding, is so, how often and how much. Is bladder
distended? Does she or did she have a catheter? If the catheter has been discontinued, what time
was it? All postpartum patients should void by six hours after delivery or Foley removal. All

postpartum moms should have their urine measured the first three voidings to ensure adequate
emptying of the bladder. These voidings should be at least 150 cc's. Remember, the mom's blood
volume increased during the second and third trimester, and diuresis takes place to return to pre-
pregnancy status.
Frequent, small voids may be indicative of retention or infection. This is a good time to find out if
the mom is performing peri care with each use of the bathroom. If she is not, then by all means
teach her according to the process of your hospital uses.
BOWEL: Daily ask the patient if she has had a bowel movement. If no bowel movement by the
second day, she may need a stool softener or a laxative. Encourage increase in fluid and juices along
with increasing intake of fruits and vegetables. Ambulation helps too.
LEGS: Check Homan's sign, and chart with cardiovascular status.
TEACHING: Talk with your mom during the assessment, and teach her the things about her care
as you go along. EXAMPLE: Peri care when checking the perineum, rationale for sitz bath and peri
light,use of local analgesics, hemorrhoid treatment, rationale for ambulation especially if a C-
section, etc.
PSYCHOSOCIAL: Note mother/father infant bonding and chart. Is mom stroking the infant,
talking to the infant, calling the infant affectionate names, or just looking affectionately at the
infant. A lack of bonding may be noted by bottle feeding the infant in the crib, or spending time on
the phone when the infant is in the room. Evaluate the mom's emotional status, explain the
hormonal changes that are occurring, and that her emotions may change from high to low quickly.
She may cry easily, but these changes are normal. Informing the family members of these changes
helps too.
POSTURAL HYPOTENSION: Caution the mom to move slowly upon sitting or getting out of bed.
Assist her the first few times she is up. Stay in the bathroom or close by the first time she showers
or when taking a sitz bath. Remind her NOT TO LOCK the bathroom or shower doors. Be
CERTAIN your mom can reach and has been instructed in the use of the call bell in the bathroom
or shower as well as her bed.
REMEMBER:
WEAR YOUR GLOVES WHEN CHECKING A POSTPARTAL PATIENT.

Correct position of hands for fundal
assessment
Noted when perineal lacerations are
present
Visual Aides to help you understand:
PostPartum Perineal Assessment

Villi are partially
closed
Villi are wide
open
Assessment of the perineal pad is a vital function of any PP nurse/corpsman. It is
important to have visual access to the perineum to assess if any clots are coming out with
the fundal massage.
If large amounts of bleeding are noted with clots bigger than a half dollar size call for
help. DO NOT stop massaging uterus and speak to patient in a calm voice. SBAR to RN
or OB/CNM on status of patient. Be sure the PP Hemorrhage cart is placed in room.

Your non-dominant hand should be placed on the bladder with dominant hand on top of fundus.
Aggressive massage ensures the uterus stays hard. You are the difference between a mother coming
back to have another baby and going home with her only biological child.
Uterine displacement r/t bladder conditions:
When the bladder is full of urine it can displace the uterus and cause an increase in bleeding. The
bladder is a bully and will fight for pole position in the uterus. During pregnancy the bladder had to
obey the uterus as a baby was growing and taking up more space. Now with the uterus very tired,
and is weak it is easily bullied. When the bladder is over 600ml filled it will push the uterus over
the right hip. During fundal assessments, if it is not located midline start looking towards the right
hip. If not there look down by the pubic symphysis.
Charting Fundal
Assessment
Fundus Firm, midline,
lochia small, no clots
Out of parameters
fundal assessment
Fundus: massage to
firm or boggy
Deviated to Right,
Moderate or heavy
bleeding,
clots noted (note size
of clots)

Breastfeeding
Research has shown that breast milk is the superior infant food. The numerous benefits of
breastfeeding for both mother and infant are well documented in the literature. Breastfeeding is a
highly complex, interdependent interaction between mother and infant. The knowledge of the
nursing staff provides assistance in developing the basis for long-term breastfeeding success.
At birth or soon thereafter all newborns, if baby and mother are stable, will be placed skin-to-skin
with the mother. Skin-to-skin contact involves placing the naked baby prone on the mother’s bare
chest. The infant and mother can then be dried and remain together in this position with warm
blankets covering them as appropriate. Mother–infant couples will be given the opportunity to
initiate breastfeeding within 1 hour of birth. Post-cesarean-birth babies will be encouraged to
breastfeed as soon as possible. The administration of vitamin K and prophylactic antibiotics to
prevent ophthalmia neonatorum should be delayed for the first hour after birth to allow
uninterrupted mother–infant contact and breastfeeding.
Breastfeeding mothers will be instructed about:
a. Proper positioning and latch-on
b. Nutritive suckling and swallowing
c. Milk production and release
d. Frequency of feeding/feeding cues
e. Hand expression of breastmilk and use of a pump if indicated
f. How to assess if infant is adequately nourished and
g. Reasons for contacting the healthcare professional
Parents will be taught that breastfeeding infants, including cesarean-birth babies, should be fed
on demand, 15-30 minutes per breast, a minimum of 8-12 times each 24 hours, with some
infants needing to be fed more frequently. Infant feeding cues (e.g., increased alertness or activity,
mouthing, or rooting) will be used as indicators of the baby’s readiness for feeding. Breastfeeding
babies will be breastfed at night.
Time limits for breastfeeding on each side will be avoided. Infants can be offered both breasts at
each feeding but may be interested in feeding only on one side at a feeding during the early days.
No supplemental water, glucose water, or formula will be given unless specifically ordered by the
provider or by the mother’s documented and informed request. Prior to non-medically indicated
supplementation, mothers will be informed of the risks of supplementing. The supplement
should be fed to the baby by cup if possible and will be no more than 10–15mL (per feeding)
in a term baby (during the first 1–2 days of life). Alternative feeding methods such as syringe or
spoon feeding may also be used; however, these methods have not been shown to be effective in
preserving breastfeeding. Bottles will not be placed in or around the breastfeeding infant’s bassinet.
This institution does not give group instruction in the use of formula. Those parents who, after
appropriate counseling, choose to formula feed their infants will be provided individual instruction.

Pacifiers will not be given to normal full-term breastfeeding infants. The pacifier guidelines at
Naval Medical Center Portsmouth state that preterm infants in the Neonatal Intensive Care or
Special Care Unit or infants with specific medical conditions (e.g., neonatal abstinence syndrome)
may be given pacifiers for non-nutritive sucking. Pacifier use will not be recommended during
the establishment of breastfeeding. Naval Medical Center Portsmouth encourages ‘‘pain-free
newborn care,’’ which may include breastfeeding during painful procedures for the newborn.
Parents who bring pacifiers from home will be educated about the negative impact on
breastfeeding caused by pacifier use.
Routine blood glucose monitoring of full-term healthy appropriate-for-gestational-age infants is
not indicated. Assessment for clinical signs of hypoglycemia and dehydration will be ongoing.
Antilactation drugs will not be given to any postpartum mother.
Routine use of nipple creams, ointments, or other topical preparations will be avoided unless such
therapy has been indicated for a dermatologic problem. Mothers with sore nipples will be observed
for latch-on techniques and will be instructed to apply expressed colostrum or breastmilk to the
areola/nipple after each feeding.
Nipple shields or bottle nipples will not be routinely used to cover a mother’s nipples, to treat
latch-on problems, or to prevent or manage sore or cracked nipples or used when a mother has flat
or inverted nipples. Nipple shields will be used only in conjunction with a lactation consultation
and after other attempts to correct the difficulty have failed.
Mothers who are separated from their sick or premature infants will be:
a. Instructed on how to use skilled hand expression or the double set-up electric breast pump.
Instructions will include expression at least eight times per day or approximately every 3 hours
for15 minutes (or until milk flow stops, whichever is greater) around the clock and the importance
of not missing an expression session during the night.
b. Encouraged to breastfeed on demand as soon as the infant’s condition permits
c. Taught proper storage and labeling of human milk and
d. Assisted in learning skilled hand expression or obtaining a double set-up electric breast pump
prior to going home.
21. Before leaving the hospital breastfeeding mothers should be able to
a. Position the baby correctly at the breast with no pain during the feeding
b. Latch the baby to breast properly
c. State that the baby should be nursed a minimum of eight to 12 times a day until satiety, with
some infants needing to be fed more frequently
d. State age-appropriate elimination patterns (at least six urinations per day and three to four stools
per day by the fourth day of life)
e. List indications for calling a healthcare professional
f. Manually express milk from their breasts

Assessment of Nipples
1. Inspect nipples for the following: a. Protracted-protrudes slightly at rest. When stimulated
become erect and easy for infant to grasp.
b. Flat-difficult for infant to grasp and unchanged with stimulation
c. Inverted-rare; retract at rest and when stimulated .
d. Traumatized-cracked, blistered, fissured, or bleeding; are painful when infant nurses (refer to
Lactation Consultant, WIC Breastfeeding counselors, or LaLeche League for assistance with flat,
inverted, or traumatized nipples).
Initiation of Lactation (initial feeding)
1. Perform the following: a. Evaluate maternal discomfort and institute comfort measures for
2. Initiate feeding as soon as possible after delivery.
3. Assist with correct positioning according to mother’s choice. Use pillows for support.
4. Ensure correct latching on (wide open mouth, flanged lips)
5. Reassure mother if infant appears disinterested; some newborns are not ready to nurse
immediately; encourage her to snuggle, hold, and enjoy her infant instead. Have her lay the
infant close to her bare chest for skin-to-skin contact.
6. Offer emotional support and encourage mother to verbalize any feelings of
disappointment or rejection related to the initial feeding if infant did not nurse or did not
nurse well.
7. pain (source of pain may be incisional, episiotomy, or uterine)
Maintenance of Lactation (length and frequency of feedings)
1. Perform the following:
a. Ensure sufficient stimulation with frequent feedings: at least 8-12 feeding sessions in a 24-
hour period. Try to encourage infant to stay on for at least 15-30 minutes per breast. If infant
only takes one breast and falls asleep, start with the opposite breast the next feeding. Assure
mother that it is normal for infant to only take one breast per feeding. However, try to
encourage stimulation of both breasts when initiating lactation. Breastfed infant may eat every
1-3 hours around the clock. Assure mother that this is very normal and that she has enough
colostrum to sustain her infant.
b. Teach parents that the infant is getting enough to eat based upon the breasts becoming
softer after feeding and infant seems satisfied between feedings (this usually occurs once milk
supply is well established).
c. Encourage mother to drink to plenty of fluids (especially water) and discuss maternal diet
while lactating (no need to be on a special diet, but discuss inclusion of calcium-rich foods in
diet).
d. Discuss infant growth spurts and increased frequency of nursing sessions (usually common
is 2-3 days, 3-4 days, and at 2 weeks, 6 weeks, 3 months, and 6 months of age).

4. Positioning
a. Offer assistance with positioning. The four basic positions are the cradle hold, cross-cradle
hold, football hold, and the side-lying position.
b. Stress to mother that alternating positions each feeding helps to prevent sore, cracked
nipples and assists in draining the milk ducts.
c. Encourage mother to support her breast with the opposite hand using the “C” hold.
Latching On
a. Assist the mother in positioning her infant so that the nose is at the level of their nipple.
Have mother brush the nipple lightlyagainst the baby’s upper lip. When the infant opens
his/her mouth wide, pull the infant to the breast ensuring he/she has at least ½ to ¾ inch of
the areola, with mother’s nipple on top of the infant’s tongue.
b. To remove infant from the breast, teach mother to break the suction by inserting her finger
gently into the corner of the infant’s mouth.
6. Sore Nipples
1. Complete the following:
a. Usually associated with:latching incorrectly, waiting too long between feedings, and/or poor
positioning. Limiting feeding times does NOT prevent sore nipples!
b. Have mother express a few drops of colostrum after the feeding and rub onto the nipples and
let air-dry.
c. Encourage mother to alternate positions with each feeding so that areas of tissue breakdown
are spared from repeated mechanical trauma.
d. Determine correct latching-on and placement of infant’s tongue, lips, and gums.
7. Engorgement
a. A normal fullness often occurs in the first days of breastfeeding, however, engorgement is an
exaggerated response related to rigid feeding schedules, delayed feedings, and use of formula
supplements. Mother’s breasts become painful, swollen, and firm and the nipples become
extremely difficult for the infant to grasp.
b. Encourage early and frequent breastfeeding’s.
c. Apply warm compresses to breast and offer shower before feeding.
d. Instruct mother to perform gentle breast massage to encourage letdown and soften the
areolar tissue.

e. Utilize breast pump to soften areolar tissue. Do not pump excessively as this aggravates the
problem.
f. Encourage mother to use ice packs for relief of swelling and pain (may use frozen vegetables
wrapped in a towel after discharge).
g. Ensure the mother checks for bra tightness or underwire because these may contribute to
the problem of engorgement.
8. Infant of a Cesarean Section 1. Perform the following: a. Reassure mother who has had
cesarean sections that they can breastfeed as successfully as mothers who have had vaginal
deliveries do.
b. Medicate mother 15-30 minutes before feedings to minimize transmission of medication via
breastfeeding.
c. Encourage mother to use the football hold in order to avoid incisional discomfort. Use
pillows for support.
d. Encourage rooming-in and continued skin-to-skin contact as soon as mother is able to care
for her infant.
9. Fussy or Irritable1. Perform the following: a. This infant may have a strong sucking need and
want to nurse every hour. Encourage mother that this is normal behavior and allow infant to
nurse up to 30 minutes at each breast.
b. Encourage skin-to-skin contact and use of infant massage to calm infant.
c. Burp infant frequently (may swallow air when fussing).
d. Follow infant’s preference for swaddling.
10.Preterm or Ill Infant 1. Perform the following:a. The birth of a preterm or ill infant can be an
overwhelming experience for most parents. The immunological advantages, nutritional
components, and digestibility of breast milk are of great value to the preterm or hospitalized
infant.
b. Encourage and support mother’s decision to breastfeed.
c. Provide a hospital grade electric breast pump and instruct mother on its use and cleaning
while separated from her infant. Begin pumping as soon as possible after delivery.
d. Until the physician gives permission for the infant to breastfeed, encourage skin-to-skin
contact of the infant with mother/significant other. This action can help with the letdown
reflex.
e. Encourage mother to use relaxation techniques, or look at a picture of her infant before
pumping.
Pump at least every 3 hours (15 minutes per breast with single pump, or 15 minutes total with a
double pump). Using the double pump when prolonged pumping is necessary is especially
helpful (use the Your Guide to Breastfeeding and What If I Need Help information sheet for
breastfeeding resource information).

g. Consult with the Lactation Consultant, WIC Breastfeeding Counselor, or a LaLeche League
for further information and assistance with breastfeeding the preterm infant.

Newborn Nursing
Caring for the newborn takes developed skills which you will gain over time to understand what is
normal and not normal in newborns. Your name will be on the chart for 21 years. This is the statute
of limitations for pediatric care. Keeping up with good communication between yourself, the RN
and the Pediatric provider is the vital key to keeping the newborn safe from potential harm.
Must know history prior to caring for the newborn:
Condition of the Newborn:
It is important to know what the APGAR scores were for the baby, any resuscitative measures
taken, physical examination, vital signs, voids, stools. It is important to note any complications
from delivery: excessive mucus, delayed spontaneous respirations or responsiveness, abnormal
number of cord vessels, obvious physical abnormalities.
Does the baby have blue moments? What causes this? His/her hands and feet are blue. Is this
normal? The baby has brown spots on its back? What does this mean? These are all normal
questions to ask and understand in order to adequately care for the newborn.
Also, remember the newborn continues to have some of the mother’s hormones circulating in it
system. You will notice breast buds in all babies. This is normal and will subside in a week or so as
the mother’s hormones are filtered and exiting the body. In females the occurrence of a tinge of
blood on the diaper is also due to maternal hormones. This does not occur in every female infant
and is normal. Make a note in the chart under the assessment that it is present. For male’s the
scrotum can appear very big. This is also due to maternal hormones. In a week or two the baby will
have the normal appearance.
Labor and birth record:
It is important to know what factors played in the birth of the newborn. Does the mother have a
positive Group Beta Strep (GBS) history and was she adequately treated before delivery? What will
this mean for the newborn? Group B streptococcus (GBS) is a type of bacterial infection that can
be found in a pregnant woman’s vagina or rectum. This bacteria is normally found in the vagina
and/or rectum of about 25% of all healthy, adult women. Women who test positive for GBS are said
to be colonized. A mother can pass GBS to her baby during delivery.
GBS affects about 1 in every 2,000 babies in the United States. Not every baby who is born to a
mother who tests positive for GBS will become ill. Although GBS is rare in pregnant women, the
outcome can be severe. As such, physicians include testing as a routine part of prenatal care. If you
test positive for GBS, this simply means you are a carrier. Not every baby who is born to a mother
who tests positive for GBS will become ill. Approximately 1 out of every 200 babies whose
mothers carry GBS and are not treated with antibiotics will develop signs and symptoms of GBS.
There are, however, symptoms that may indicate you are at a higher risk of delivering a baby with
GBS.
These symptoms include:
 Labor or rupture of membranes before 37 weeks

 Rupture of membranes 18 hours or more before delivery
 Fever during labor
 A urinary tract infection as a result of GBS during your pregnancy
 A previous baby with GBS
In this case the physician will want to use antibiotics to protect the baby from contracting GBS
during delivery. Newborns who are delivered without adequate treatment of GBS have an increased
risk of developing sepsis. Mothers may have 1 dose of PCN on board prior to delivery. These babies’
will be watched very carefully for infection.
How does Group B Strep affect a newborn baby?
Babies may experience early or late-onset of GBS.
The signs and symptoms of early-onset GBS include:
 Signs and symptoms occurring within hours of delivery
 Sepsis, pneumonia, and meningitis, which are the most common complications
 Breathing problems
 Heart and blood pressure instability
 Gastrointestinal and kidney problems
Early-onset GBS occurs more frequently than late-onset. Intravenous antibiotics are used to treat
mothers and newborns with early-onset GBS.
The signs and symptoms of late-onset GBS include:
 Signs and symptoms occurring within a week or a few months of delivery
 Meningitis, which is the most common symptom
Late-onset GBS could have been passed during delivery, or the baby may have contracted it by
coming in contact with someone who has GBS.
Reviewing the birth record can supply you with important information:
 Duration, course and status of mother and fetus throughout the labor and birth
Babies can be very tired, Just as tired as the mothers. Babies have up to 6 hours to eat for
their first feeding. The time of the first feeding is important as it will determine when you
can complete the Newborn Screen Testing (PKU, cardiac testing, and Bilirubin)
 Analgesia or anesthesia administered to the mother (esp. used 1 hour prior to birth)
When narcotics are given within 1 hour of birth, the newborn will exhibit a depressed
respiratory rate. They will need resuscitative measures to help them breathe.
 Prolonged rupture of membranes

When rupture of membranes have been ruptured for long hours (typically >24 hours) the
risk of chorioamnionitis is increased. This infection is in the water around the baby. The
baby “breathes” the fluid in which creates a medium for bacterial growth.
 Abnormal fetal position
When babies are breech the hips can be out of alignment and exhibit the Ortolanie Click.
Report back to the CNS and describe the Ortolanie Click and what can be done for it. Or
the baby could have been head down, but malposition resulting in a cone head appearance.
The skull is soft and moveable allowing the skull to overlap (like tectonic plates) so the
head can fit through the maternal pelvis.
 Presence or absence of meconium stained fluid
Babies who are term (38 weeks – 42 weeks) can have “mature” CNS which signifies the baby
is ready to be born. Sometimes there has bene trauma causing the baby to poop in utero.
The degree or thickness of the fluid determines how much the baby was distress in utero.
Light Mt. Dew fluid is normal in term baby’s. Darker, pea soup indicates distress in utero.
The baby “breathes” the fluid which does not pass through the vocal cords. It is once the
baby cries and opens up that airway that the mec. Fluid is able to pass through to the lung
fields. Meconium is thick, sticky fluid that can hinder the alveoli from truly opening up for
oxygen. The newborn will display respiratory distress (nasal flaring, substernal and
intercostal retractions, grunting). Peds is present for delivery.
 Signs of non-reassuring fetal tracings
Babies are being squeezed every 2 minutes or so while in labor. For most baby’s this is a
nice feeling of being squeezed. But, sometimes the baby does not like it and will show it
doesn’t through the fetal strip. Variable decels during labor indicate cord compression, late
decels indicate oxygen deprivation from the placenta. Peds is present for delivery
 Nuchal cord
The baby’s have their own bounce house. They have grown from this littlepeanut to a big
butterball or small chicken. The umbilical cord can get wrapped around their neck. We
cannot help that and nor can mom or dad. What we can do is monitor the baby during
labor.
 Precipitous birth
Precipitous births result in fast deliveries. The mother’s cervix dilated so fast that the baby
descended into the pelvis and birth canal to cause bruising on the baby’s face or shoulders.
 Use of forceps or vacuum for delivery
When mother’s are pushing for long hours (first time mom’s up to 4 hours, second time
moms’ average 20 minutes) forceps (spoons) and a vacuum may applied to help facilitate a
quick birth once the baby gets under the pubic symphysis. The baby showed signs of
distress to where the use of forceps and/vacuum were needed. With forceps delivery the
baby may have some bruising on the sides, near the cheeks of the face. With vacuum there
is an increased risk of developing cephalohematoma’s because the skin is pulled away from
the skull. Peds is present for both deliveries.
 Antibiotics given during labor
This applies to the Group Beta Strep. It is explained above.

Parent-Newborn Interaction:
It is important to note the interaction between mother/father and baby. 70% of mothers have some
form of postpartum blues. 30% of mothers exhibit signs of postpartum depression.
*I would like a 1-2 page essay on the difference of these and what to look for between PP blues and
depression.
Airway Clearance and Stable Vital Signs
Newborn vitals
Any vitals out of parameters
the physician should be
notified. Remember to
document paging of MO in
Essentris

Measurements of the newborn:
While on 4M the newborn is weighed and measured. But, it is still a good skill to have in case you
need to take measurements.
Feedings: Can
you help my
mommy feed
me?

Head to Toe Assessment:
Fontanels:
The head to toe assessment is a vital component for assessing a stable newborn status. You will
look at the head. Note the baby may have a cone head appearance. This is normally seen in the first
24 hours after delivery. The newborns head molded to fit through the pelvis. The skull is soft and
not fused together like you would see in an adult. The soft skull will mold (like tectonic plates)
which allows the skull to move over each other to allow for molding. When the newborn sits on the
cervix for a long time or in the vagina the skull will mold to fit through.
Circumcision:
Is a surgical elective procedure in which the prepuce, (epithelial layer covering the penis) is
separated from the glans penis and excised. Your role would be to alleviate some of the anxiety the
new parents feel when their baby is taken for the procedure. Some risks of the procedure are
hemorrhage, infection, difficulty voiding, separation of the edges of the circumcision, discomfort,
restlessness. Be sure to educate the parents on liberal use the petroleum jelly on the penis head and
on the diaper. If the diaper is dried on to the penis DO NOT PULL IT OFF! Grab a soaking wash
cloth and wring it out over the penis and diaper. Pull the edges slowly as the water releases the
dried blood from the penis to the diaper. If any difficulty notify the provider right way. If
hemorrhaging apply pressure to the wound can call for help.
Newborn medications:
These medications are given on 4M:
Erythromycin ointment for the eyes:
Once in a while parents ask whether babies get silver nitrate drops in their eyes. They don’t and
hospitals haven’t used that stuff for decades. We do, however, put antibiotic ointment (usually
erythromycin) in their eyes. Why? Just in case their mother has Chlamydia or gonorrhea. It kills
other germs as well, but the reason why newborn eye treatment is mandatory is to prevent
blindness caused by these two STDs. But aren’t all mothers tested for STDs during pregnancy? Yes,
they are. Occasionally, a mother picks up a case of something nasty after she’s tested, but before
her baby is born. Public health officials want to cover those “just in case” cases. Yeah, it’s a little off-
putting and most parents won’t be told that’s why we do it. Instead, they’ll be told, “all kinds of
germs get into babies eyes.” Sounds better, right?
Vitamin K:
The baby will get Vitamin K injected into his leg, in case he’s among the 0.25% to 1.7% of babies
born with vitamin K deficiency bleeding—a serious bleeding disorder that can cause healthy-
appearing babies to hemorrhage because they don’t have enough vitamin K to clot their blood. A
single vitamin K shot, reduces chances of VKDB significantly. Most states mandate that all babies
receive vitamin K as soon as possible (usually within the first hour) after birth. Parents can sign a
waiver if they object in some states, but they’ll be given some grief about it. They can also opt for
oral vitamin K, though it requires multiple doses to be given by parents. The shot is fast and while
most babies cry when they get it, it’s over and done with in about a second. Oral vitamin K tastes
nasty (I’ve tried it) and while it may save a baby from getting poked, it requires he suck back that
nasty flavor many times.

Trick to
successfully
drawing blood
for PKU: Place
heel warmer 5-
10 mins before
test. Hold
babys foot in
dependent
position, blood
flows faster
Hepatitis B:
Hep B causes serious liver inflammation due to infection with the hepatitis B virus. It’s spread
through having contact with the blood, semen, vaginal fluids, and other body fluids of someone
who already has a hepatitis B infection. A series of three vaccinations prevents people from getting
Hep B, which can cause liver failure.
Newborn Screensthat will be completed before discharge:
PKU
It is very important to know when the first feeding was initiated. This will determine when the PKU
can be completed. PKU is a metabolic disorder which the body cannot convert the common protein
amino acid. The child will exhibit an intolerance to feed which will lead to a failure to thrive. If this
condition is left untreated the child can die.
Be sure to completely
saturate the circles with
blood, keeping in the
dotted circles. Must be
completed 24 hours after
the first feeding.

Cardiac Testing
Screening for Critical Congenital Heart Defects
Babies with a critical congenital heart defect (CCHD) are at significant risk of disability or death if
their condition is not diagnosed soon after birth. Newborn screening using pulse oximetry can
identify some infants with a CCHD before they show signs of the condition. Once identified, babies
with a CCHD can be seen by cardiologists (doctors that know a lot about the heart) and can receive
special care and treatment that can prevent disability and death early in life.
About 1 in every 4 babies born with a heart defect has a critical congenital heart defect (critical
CHD, also known as critical congenital heart disease).1 Babies with a critical CHD need surgery or
other procedures in the first year of life. Learn more about critical CHDs below.
What are Critical Congenital Heart Defects (Critical CHDs)?
In the United States, about 7,200 babies born every year have critical CHDs.2 Typically, these types
of heart defects lead to low levels of oxygen in a newborn and may be identified using pulse
oximetry screening at least 24 hours after birth. Some specific types of critical CHDs are listed in
the box to the right. Babies with a critical CHD need surgery or other procedures in the first year of
life. Other heart defects can be just as severe as critical CHD and may also require treatment soon
after birth.
Importance of Newborn Screening for Critical CHDs
Some CHDs may be diagnosed during pregnancy using a special type of ultrasound called a
fetalechocardiogram, which creates pictures of the heart of the developing baby. However, some
heart defects are not found during pregnancy. In these cases, heart defects may be detected at birth
or as the child ages.
Some babies born with a critical CHD appear healthy at first, and they may be sent home before
their heart defect is detected. These babies are at risk of having serious complications within the
first few days or weeks of life, and often require emergency care. Newborn screening is a tool that
can identify some of these babies so they can receive prompt care and treatment. Timely care may
prevent disability or death early in life.
Bilirubin Testing
Bilirubin is a yellow pigment that is in everyone’s blood and stool. If you notice a yellowing of your
skin or the whites of your eyes, this is called jaundice, and it may be caused by high levels of
bilirubin.
Bilirubin is made in the body when old red blood cells are broken down. The breakdown of old cells
is a normal, healthy process. After circulating in your blood, bilirubin then travels to your liver. In
the liver, bilirubin is excreted into the bile duct and stored in your gall bladder. Eventually, the
bilirubin is released the small intestine as bile to help digest fats and ultimately excreted with your
stool.
Bilirubin attached to sugar is called “direct” or “conjugated” bilirubin, and bilirubin without sugar is
called “indirect” or “unconjugated” bilirubin. All the bilirubin in your blood together is called
“total” bilirubin.

Why test for bilirubin?
If bilirubin is not being attached to sugars (conjugated) in the liver and/or is not being adequately
removed from the blood, it can mean that there is damage to your liver. Testing for bilirubin in
the blood is therefore a good test of damage to your liver.
Newborn infants often have some jaundice, and bilirubin in the blood may be tested several times
in the first few days of an infant’s life to check that the liver is starting to work properly. Jaundice in
a newborn can be very serious if left untreated.
Other reasons for high bilirubin levels could be that more blood cells are being destroyed than
normal. This is called hemolysis.
Sometimes bilirubin is measured as part of a “panel” of tests. Often, the liver is evaluated with a
group of tests that include bilirubin, alanine transaminase (ALT), asparate transaminase (AST),
alkaline phosphatase (ALP), albumin, total protein, and others.
In a newborn, higher bilirubin is normal due to the stress of birth. Normal bilirubin in a newborn
would be under 5 mg/dL, but up to 60 percent of newborns have some kind of jaundice and
bilirubin levels above 5 mg/dL.

Kernicterus
Kernicterus is a rare neurological condition that occurs in some newborns with severe jaundice.
Kernicterus is caused by very high levels of bilirubin. Bilirubin is a yellow pigment that is created as
the body gets rid of old red blood cells. High levels of bilirubin in the body can cause the skin to
look yellow (jaundice).
If levels of bilirubin are very high or a baby is very ill, the substance will move out of the blood and
collect in the brain tissue. This can lead to serious complications, including brain damage and
hearing loss. The term "kernicterus" refers to the yellow staining caused by bilirubin. This is seen in
parts of the brain on autopsy.
Kernicterus most often develops in the first week of life. However, but may be seen up until the
third week. Some newborns with Rh hemolytic disease are at high risk for severe jaundice that can
lead to this condition. Rarely, kernicterus can develop in seemingly healthy babies.
The symptoms depend on the stage of kernicterus.
Early stage:
 Extreme jaundice
 Absent startle reflex
 Poor feeding or sucking
 Extreme sleepiness (lethargy) and low muscle tone (hypotonia)
Mid stage:
 High-pitched cry
 Arched back with neck hyperextended backwards (high muscle tone/hypertonia)
 Bulging fontanel (soft spot)
 Seizures
Late stage:
 High-frequency hearing loss
 Intellectual disability
 Muscle rigidity
 Speech difficulties
 Seizures
 Movement disorder

A blood test will show a high bilirubin level (greater than 20-25 mg/dL).
Note: Normal value ranges may vary slightly among different laboratories. Talk to your doctor
about the meaning of your specific test results.
TREATMENT
Treatment depends on how old the baby is (in hours) and whether the baby has any risk factors
(such as prematurity). It may include:
 Light therapy (phototherapy)
 Exchange transfusions
Hypoglycemia in the newborn
Glucose is the major energy source for the fetus and neonate. The newborn brain depends on
glucose almost exclusively. Glucose regulatory mechanisms are sluggish at birth. Thus, the infant is
susceptible to hypoglycemia when glucose demands are increased or when the glucose supply is
limited. Untreated hypoglycemia in the neonate may cause neurologic abnormalities or death. Pre-
planning and admission screening will minimize the risk to infants due to hypoglycemia.
General:
1) Initiate Feedings: Feeding should be initiated for all neonates as soon as the infant is ready,
within 1 hour of birth unless medically contraindicated (e.g. respiratory distress with tachypnea).
Neonates who are not fed will have a physiologic drop in blood glucose, with a low at 1 to 1.5 hours
of age. The feeding should be breast milk (preferred) or infant formula (if parents choose or
breastfeeding is medically contraindicated).
2) Assess risk factors and symptoms: All neonates with risk factors or signs of hypoglycemia should
have their blood glucose checked.
3) Screen and manage based on initial feeding and assessment: If the neonate is symptomatic or the
blood glucose falls below the treatment threshold, notify MO immediately. Use the algorithm
provided below.
Family members may be present to observe the procedure at the discretion of the nursing staff. Any
infant with severe hypoglycemia (serum glucose of <25 mg/dl) will be admitted to the NICU for IV
glucose therapy. Initiation of IV placement and glucose therapy may be started in the
Observational Nursery if needed, with subsequent transfer to the NICU. Any infant with persistent
hypoglycemia (continued low blood glucose levels even after oral feeds) will be admitted to the
NICU for IV glucose therapy. Any infant with hypoglycemia who is unable to feed, secondary to
respiratory distress, will be transferred to NICU for IV glucose therapy.
CANDIDATES- Infants who meet at least one of the following criteria:

1. Infants of diabetic mothers
2. Large for gestational age (LGA) infants (>4300 gms or >90%)
3. Small for gestational age (SGA) infants (<2500 gms or <10%)
4. Preterm infants (EGA < 37 weeks)
5. Intrapartum depression (5 minute APGAR <7)
6. Cold Stress/Hypothermia (<36.50 axillary after stabilization)
SYMPTOMATIC INFANTS
Signs of hypoglycemia include irritability, tremors, jitteriness, exaggerated Moro reflex, high-
pitched cry, seizures, lethargy, floppiness, cyanosis, apnea, poor feeding.
Check blood glucose immediately (minutes, not hours) for symptomatic infants. This includes
those infants with clinical signs of hypoglycemia even if they do not fall into any of the high risk
categories. If <40 mg/dl, repeat immediately, notify MO for orders, send confirmatory
sample to lab for STAT serum glucose to verify result. Typical orders will include transfer to
higher level of care and iv glucose (2 ml/kg D10 bolus followed by 5-8 ml/kg/min (80-100
ml/kg/day).
ASYMPTOMATIC, AT-RISK INFANTS
Birth to 4 hours of age
Provide initial feed within one hour of life, For breastfed infants after C/S delivery, maximize efforts
to reunite mother and infant. Obtain screening glucose 30 minutes after first feed. If baby is not
interested in feeding right after birth or has not fed due to separation from breastfeeding mother,
check blood glucose within 2-3 hours of birth. Sample may be obtained by heel stick or venous
sampling.
If glucose > 40 mg/dL, no additional action required until blood glucose check prior to next feeding
unless infant develops signs of hypoglycemia.
If glucose 25-40 mg/dL, repeat blood glucose (and send confirmatory serum glucose) but do not
delay feeding infant more than 5 minutes whileobtaining labs. Check glucose in 30 minutes after
feed. If initial feed was breastmilk, and repeat blood glucose is not >40mg/dl, feed infant 10-20 ml
formula and recheck in 30 minutes.
If glucose <25 mg/dL, repeat immediately to verify result. If the repeat value is <25 mg/dL, notify
MO, and send confirmatory sample to lab for STAT serum glucose value. Patient may be fed while
awaiting iv insertion. Admit to higher level of care for IV glucose.
4 to 24 hours of age

Continue to feed infant on demand, but at a minimum of every 2-3 hours with qAC glucose checks.
For infants feeding more frequently than q2-3 hrs, qAC BG checks in asymptomatic infants should
be checked no more frequently than q2-3 hrs. Infant must have at least 3 consecutive values >40
mg/dL in order to stop these routine qAC glucose checks. If glucose > 40 mg/dL, no additional
action is needed unless infant develops signs of hypoglycemia.
If glucose 25-40 mg/dL, notify M.O., repeat blood glucose (and send confirmatory sample to lab for
STAT serum glucose to verify result) but do not delay feeding infant more than 5 minutes while
obtaining labs. Check glucose in 30 minutes after feed. If this feed was breastmilk, and repeat blood
glucose after feed is not >40mg/dl, feed infant 10-20 ml formula and recheck again in 30 minutes.
If glucose <25 mg/dL, repeat immediately to verify result. If the repeat value is <25 mg/dL, notify
MO, and send confirmatory sample to lab for STAT serum glucose to verify result. Patient may be
fed if RR <60 while awaiting iv insertion. Admit to higher level of care for IV glucose.
A follow up BG will be done 30 minutes after the completion of any feed given for BG <40 mg/dL.
If the follow up glucose is ≤ 40 mg/dl, notify the M.O. If the follow up glucose is > 40 mg/dl, then
complete the hypoglycemia protocol as ordered.

NMCP Maternal Newborn Nursing Orientation Information Packet

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