alternatives to mother/baby care in hospital

JaneyW · Mar 11, 2008

I have worked at three different hospitals with different set-ups and also work registry so have seen many more. If I were to design a 'best practice' way to handle it, it would be this:

Have PP be couplet care with one nurse for both the mother and the baby. There should be a max of 3-4 couplets per nurse depending on acuity. That seems to be the best system for avoiding things falling through the cracks. You know the needs of the baby and the mom have been addressed because the same person addressed them.

Have a PP nurse assigned to catch babies each shift. She should not have responsibilities in the nursery that would keep her from going to deliveries. Have the scale, measuring, footprint stuff, etc on a movable cart that she can take to the delivery room. Babies should be recovered in the room with their parents allowing for that bonding and eliminating the separation as recommended by the AAP. This will promote breastfeeding as well. What happens if there aren't any deliveries expected? She can help her fellow PP nurses--maybe even take an easy couplet--but her priority is to the delivery.

Now, I work in California where we have ratios and am seeing more charge nurses without assignments. This allows for someone to "jump in" if needed. The charge nurse should know what is going on with all the patients, but there may not be time for everyone to hear rounds (Oh but for a perfect world!).

It sounds like you are in a teaching hospital which causes its own problems. You probably need someone in the nursery to help the residents round. Can this be the charge nurse? OK, I know this is a stupid question but here goes---can the peds be trained to do things differently in order for the nursing staff to be used more efficiently? I know, it is a long-shot but I had to throw it in there.

I think maybe your first step would be to narrow you focus and have clearly defined goals or problems that you are solving. Break it down and get input from those involved. Good luck with this. These are changes that need to be made.

Elvish, BSN, DNP, RN, NP · Mar 11, 2008

We do not have 'true' couplet care at my hospital. We encourage 24hr rooming-in and I'd say probably 75% do it on average. So this is our set-up:

L&D does the deliveries, and if there's a problem, NICU is at the delivery.

Nursery doesn't go to deliveries. I kind of wish we did, but we don't. We take over once L&D brings baby to us. (Or we go out to the room to bathe/measure/shots/drops if mom doesn't want to be separated.)

We have one charge RN and one 'second RN' in nursery. Charge nurse communicates w/ peds about stuff and makes sure things like bilis, circ consents, blood cultures, get done when applicable. Second nurse does admissions, and between the two of us we feed/change/etc. whoever else is in there for whatever reason. Nights when L&D looks bad or we have a lot of babies whose moms have been d/ced (baby on lights etc.), we have 3 nurses in the nursery.

Couplet nurses usually have 4-5 couplets. They are responsible for assessing, weighing, & bathing the babies & bringing anything abnormal to the nursery charge nurse's attention. They also help with feeding and teaching about infant care.

So really the nursery nurses don't step out of the nursery most nights. We take babies out to moms for feeds (or if she's still in L&D on pp mag & wants to see baby) if the couplet nurse is otherwise busy, but most of the time there's enough going on to keep us hopping.

There is definitely room for improvement in this set-up but the idea of a charge RN in the nursery does help with making sure things like bilis, blood cultures, car seat tests etc. get done.

Love_2_Learn · Mar 11, 2008

Great suggestions from JaneyW!!

As far as providing initial newborn care, we had one nurse assigned to that position each day. Since we did not have LDRP, the babies would spend 30 to 45 minutes in L&D nursing/bonding & then come to our mother-baby unit to our transition nursery for the next couple of hours before joining mom as she arrived from the L&D unit. Our hospital was too busy to have LDRPs. I can see how that can be a problem though and JaneyW's suggestion sounds wonderful.

When our post-partum & well baby nursery combined many years ago (not LDRP) we had a very small nursery on the post-partum floor which was not supposed to hold more than about 6-8 babies. All babies were encouraged to be in their Mom's room (OB's and prenatal class instructors taught that this was going to be expected in the hospital and that each Mom should try to line up a couple of people to plan to stay in the room with her after delivery. We found that anticipatory guidence to be very helpful.)

Anyway, with such a small nursery our pediatricians began to do their morning or evening rounds in the Mom's room. Sure, at first they had loads of complaints at first, but after a few months they actually enjoyed it. They would come into the little nursery, grab & review the baby's chart, then head to the Mom's room. This gave the pediatrician an opportunity to answer the parent's questions, point out special things about their baby, etc. The pediatricians also said that after discharge they noticed the first baby visits in their office went much faster and smoother because of the interaction they had with the parents & baby in the hospital. Go figure... a silver lining to the dark cloud of having to assess babies in the Mom's room.

I don't know how many other hospitals have the pediatricians do their baby rounds in the parent's room & I'd be curious to know if that hospital was in line with what some hospitals are doing now.

By the way, we had an area in the little nursery where the OB's could perform circumcisions. They would usually do them during their evening rounds the night before the baby was expected to be discharged. They would go to the room with a nurse, talk about the circumcision & answer any questions the parents had, the nurse and doctor would take the baby to the nursery, perform the surgery, and then the baby came back to the parent's room to be soothed and consolled after the procedure. The parents learned and performed circumcision care that evening/night/morning and the circumcision had a chance to begin to heal and for nurses to observe for problems. (Where I work now the OB's prefer to do the circ's in the morning, usually of discharge, so the circumcision site is only monitored for a few hours and parents don't get as much feedback and experience in circumcision care.)

I apologize for the long post. Just adding my :twocents: .

HvnSntRN · Mar 11, 2008

My mother baby unit does 24-hour rooming in. We have not had a nursery for our postpartum patients for almost a year. The nursery "space" still exists - we use it for patient teaching (baby bath class), observing students as they do their assessments, newborn exams by peds, doing bloodwork on babies, and the lighting is the good for doing newborn assessments especially if we are concerned about jaundice. If parents want to do a supervised baby bath, this is a good location to do it.

We usually have up to 4 couplets as our assignment, and my routine is to do mom and baby's assessments at approximately the same time. We have portable scales on the unit so we often weigh babies right in the rooms, and involve the parents and use the opportunity to do as much teaching as I can. This also promotes non-separation of mom and baby. My practice is to have diapers, pads, towels, baby gowns stocked in the cabinet of the portable scale, so I can restock the patients' supplies when I'm doing the initial assessments and remove dirty linen from the bassinette before going to the next patient.

The rooms have ceiling potlights on dimmer switches so we keep them on through the night so we can monitor baby at the bedside when we do rounds. We are often in the rooms q1-2h overnight, especially when mom is breastfeeding - I encourage my patients to put on the call bell when they are awake and feeding and I will go in to record the feeding and diaper change and do any assessments that I need to do. There's nothing more valuable to exhausted parents than the opportunity to have a couple of hours of uninterrupted sleep; I explain that to them and encourage them to use the call bell when they are up so that I am not waking them unnecessarily.

We also have most dads staying overnight too as additional support for mom. When dad is staying, I let him know that he's part of the team and he's going to be helping! When mom is clusterfeeding through the night, he's going to be the one getting her drinks and snacks, and he's going to be the one rocking the baby or taking baby for a walk if mom needs a catnap and baby won't settle. This prepares him for the teamwork that lies ahead. Most of the dads love to be involved but have no idea where to begin.

We don't have patients on MgSO4 on the unit - they stay in L&D. But we do get PPHs and hang blood transfusions and fresh c-sections and moms with twins and moms with babies in the NICU.

Things have changed a lot in our institution over the last 10 years, but I really love the intimacy of family centred care and helping new families in the precious early hours of their baby's life.