Effective Date: November 15, 2013
Category: Clinical
Title: Perinatal – Protocol for Newborn Transition
Applies to:
St. Peter’s Health Partners (SPHP)
All SPHP Component Corporations
The following SPHP Component Corporations:
__St. Peter’s Hospital_________
St. Peter’s Health Partners Medical Associates (SPHPMA)
TABLE OF CONTENTS
PURPOSE ..................................................................................................................................................... 1
POLICY STATEMENTS ............................................................................................................................. 1
SCOPE OF AUTHORITY / COMPETENCY.............................................................................................. 2
PROCEDURE ............................................................................................................................................... 2
Appendix A: Neonatal Resuscitation Program 6th Edition Algorithm
Mosby's - Apgar Score
LINKS
Protocol - Hypoglycemia Management - Adults and Children 2 Years of Age and Older
Perinatal - Hypoglycemia Protocol for Neonatal Patient
Perinatal - Thermregulation of the Neonate
Perinatal – Identification of Newborns
REFERENCES ............................................................................................................................................. 4
PURPOSE
To specify the nursing responsibilities in the care of the newborn from delivery through the first two
hours of life.
POLICY STATEMENTS
The first two hours of life are significant, as the newborn makes the critical transition from intrauterine to
extrauterine life. Approximately 10% of newborns require some assistance to begin breathing that
includes stimulation at birth, and less than 1% will need extensive resuscitative measures. Preparation of
neonatal resuscitation equipment, assessment of the newborn, and availability of personnel qualified to
initiate neonatal resuscitation measures are essential to ensure that the transition to extrauterine life is
successful.
Title: Perinatal – Protocol for Newborn Transition
Effective Date: November 15, 2013
Page 2 of 6
SCOPE OF AUTHORITY / COMPETENCY
Independent
PROCEDURE
I. INITIAL POST-DELIVERY CARE
A. Note time of delivery
B. Dry newborn with a warm blanket. Clear airway and stimulate, if necessary.
C. If newborn is of term gestation, exhibiting breathing or crying efforts with good muscle tone,
place on mother’s abdomen or chest and continue ongoing assessment and support to the mother/
family.
If newborn is premature, exhibits poor muscle tone or evidence of cardiopulmonary
distress: Move newborn to radiant warmer and institute interventions as per Neonatal
Resuscitation Program (NRP) guidelines.
(See Appendix A: Neonatal Resuscitation Program 6th Edition Algorithm)
If with mother: Use skin-to-skin (STS) contact and place a hat on baby and warmed
blankets over baby and mother.
D. If on radiant warmer: Place on dried warm blanket uncovered. Assess heart rate, respiratory
rate, tone, reflexes and color to calculate APGAR scores at 1 and 5 minutes. Continue APGAR
scoring q5 minutes until greater than 7 or up to 20 minutes of life; document APGARs and NRP
interventions in the perinatal delivery summary. If Neonatology is present for the delivery, the
Registered Nurse will confer with the Neonatologist for assignment of scores before
documentation. (Mosby's Nursing Skills - Apgar Score and NRP Interventions)
E. Apply plastic cord clamp 1 inch from newborn’s abdomen, trim umbilical cord on distal side of
clamp and examine for presence of 2 arteries and 1 vein; document findings.
F. Cord Blood Collection:
1. After specimen(s) are collected by the delivery attendant (MD/CNM/Resident), label
specimens and process laboratory slips per physician/provider orders.
2. The following specimens are to routinely be collected when indicated:
a. Umbilical Arterial and Venous Cord Blood pH (recommended for all unscheduled
cesarean sections and operative vaginal deliveries)
b. If mother is Rh negative: CBC with differential, Total & Direct Bilirubin, and ABO/Rh
Type and Direct Coombs
c. If mother is O positive: Hold Clot
d. If mother’s blood type is unknown: collect and hold bloods for CBC with differential,
Total & Direct Bilirubin, and ABO/Rh Type and Direct Coombs until maternal ABO and
Rh are determined
e. If mother’s HIV status is unknown and maternal expedited testing is refused: HIV 1/2
Antibody Expedited (mother’s consent not required)
f. Other cord blood samples as determined to be clinically relevant by the Clinical Chief or
the maternal and/or neonatal Attending Physician(s)
3. Umbilical cord blood for banking or donation may be obtained at the request of the patient
and in the absence of other contraindications. The cord blood bank selected by the patient
must be approved for operation in New York State. Collection, packaging and dispatch of
blood to the selected cord blood bank is done in accordance with the directions provided by
the cord blood bank via the patient. Transportation of the blood to the bank is the
responsibility of the patient.
Title: Perinatal – Protocol for Newborn Transition
Effective Date: November 15, 2013
Page 3 of 6
G. Administer Vitamin K and Erythromycin eye ointment, within 1 hour of birth. Explain rationale
to parent for both.
H. Newborn Identification:
1. Place 2 bracelets on baby (ankle and wrist), right ankle bracelet will also have security sensor
attached; one bracelet on mother; 4th bracelet is placed on mother's designee or sent to the
nursery attached to the baby’s chart.
2. Obtain 2 foot prints of infant and finger print of mother’s right index finger.
3. Explain/Review identification process and policy for infants safety while in hospital.
I.
Newborn Physical Assessment
Within 30 minutes of birth perform physical assessment utilizing the following parameters
and corresponding norms:
1. Respiratory
a. Rate between 30 to 60/minute
b. Clear and equal breath sounds
c. Absence of grunting, flaring, retractions, cyanosis.
2. Cardiac
a. Apical rate 120 to 160 beats/minute
b. No generalized cyanosis.
3. Temperature
a. Obtain an initial axillary temperature 36.5° C to 37.3° C.
b. If temperature below 36.5° C, place infant under radiant heat. If temperature
between 36.5° C (97.6° F) and 37° C (98.6° F), place a hat on baby and promote
skin-to-skin contact of mother and baby.
4. Weight (note in grams and pounds/ounces).
5. Muscle tone
a. Hypertonic flexion of all extremities
6. Skeletal/Skin
a. Head/Facial Symmetry.
b. Intact palate
c. Intact spine without dimpling or tufts of hair.
d. Birthmarks, bruising, areas of broken skin.
e. Symmetry of extremities.
f. Heel creases.
7. Neurologic
a. Note infant’s state of alertness
b. Intact grimace, rooting/sucking, startle reflexes
8. Elimination
a. Note voiding/or stooling
b. Visually inspect for patency of anus.
J. Notify neonatologist immediately if infant exhibits any signs of respiratory distress. Notify
neonatologist of infants who deviate from the above listed norms.
K. Implement Hypoglycemia Protocol if maternal or infant criteria are present. Hypoglycemia
Protocol for Neonatal Patient, Hypoglycemia Management
Title: Perinatal – Protocol for Newborn Transition
Effective Date: November 15, 2013
Page 4 of 6
Heart rate, Respiratory rate, temperature and color must be assessed and documented every 30
minutes for the first 2 hours. Frequent vital signs assessment will continue if the infant’s condition
is not stable.
II. INITIATION OF BONDING
A. If baby is stable initiate family/infant contact immediately after birth process.
B. Ensure privacy of the family unit.
C. Position for eye-to-eye contact.
D. Encourage parents to explore, touch, and talk to their baby.
E. If breastfeeding is planned, encourage and help with skin-to-skin positioning and infant led
breastfeeding. Educate parents on expected newborn responses.
F. If bottle-feeding is planned, encourage parents to offer bottle. Feeding should occur within 2
hours of birth.
G. Initial skin-to-skin contact should last at least 60 minutes if newborn and mother are stable.
H. Provide teaching about newborn sleep-wake states, color, feeding patterns, safety.
III. DURING RECOVERY CARE
A. After initial assessment, reassess the following parameters every 30 minutes for the first 2 hours:
color, breath sounds, pulse, respirations, and temperature (axillary).
B. Assess bonding/feeding activities at least once during the initial transition period.
IV. DOCUMENTATION
A. Complete the following:
1. Newborn assessment record at delivery
2. Perinatal Labor and Delivery Summary
3. Narrative note as required for identified problems
B. Document deviations from normal newborn transition and the nursing interventions initiated in
the progress notes or in electronic medical record notes.
V. SAFETY
A. Do not leave infant unattended.
B. Review/explain Newborn Identification Policy and Safety Policy to parents and family.
C. Hugs tag must be attached before transport to the mother-baby unit.
D. Neonatology will be notified immediately for any infant not transitioning appropriately.
E. If transporting infant to nursery in crib, position infant on back with bulb syringe available.
F. If transporting infant skin-to-skin with alert mother, position infant on stomach between mother’s
breasts with warm blankets over mother and baby. Mother should be semi-reclined on a stretcher
with side rails up or safely seated in a wheelchair.
G. Identify newborn with RN or TCA from Mother/Baby Unit upon arrival to mother-baby unit –
see Perinatal – Identification of Newborns.
REFERENCES
American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2012).
Guidelines for Perinatal Care (7th ed.). Elk Grove Village, IL: American Academy of Pediatrics..
Kattwinkel, J. (Ed). (2011). Neonatal Resuscitation Textbook (6th ed.). American Academy of Pediatrics
and American Heart Association.
Kattwinkel, J., Perlman, J.M., Aziz, K., Colby, C., Fairchild, K., Gallagher, J., Hazinski, M.F., et al.
(2010). Special Report – Neonatal Resuscitation: 2010 American Heart Association Guidelines for
Title: Perinatal – Protocol for Newborn Transition
Effective Date: November 15, 2013
Page 5 of 6
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics, DOI:
10.1542/peds.2010-2972E
Verklan, M. and Walden, M (2008). Core Curriculum for Neonatal Intensive Care Nursing. St. Louis:
Elseveir Saunders.
Approving Official: CNO; CMO
Effective Date: November 15, 2013
Key Sponsor: Neonatal CNS
Reviewed By: Chief of Neonatology; Chief of Pediatrics; Chief of
OB/GYN; Director of Women’s and Children’s; Perinatal CNS;
Perinatal Policy Workgroup; SPH Policy Council
Search Terms: perinatal, newborn transition, new born, post
delivery, assessment, cord blood, apgar, apgar score,
Replaces: Perinatal – Protocol for Newborn Transition, 7/09
Perinatal – APGAR Scoring Mosby’s, 5/12
Perinatal – Cord Blood Collection, 5/12
Original Date: 8/92
Reviewed/Revised Date: 3/94; 1997;
6/2000; 5/03; 7/09; 11/7/13
*Reviewed, No Revisions
**Revised without Full Review
Title: Perinatal – Protocol for Newborn Transition
Effective Date: November 15, 2013
Page 6 of 6
Appendix A
Neonatal Resuscitation Program 6th Edition Flow Diagram
Source: http://pediatrics.aappublications.org/content/early/2010/10/18/peds.2010-2972E.full.pdf+html