Evidence based practice for newborn care

Elvish, BSN, DNP, RN, NP · Oct 18, 2012

We do our first bath 6 hours after delivery, or after first good breastfeeding (if it takes longer than 6 hrs). Obviously if mom has HepB/C or HIV we bathe as soon as baby is stable. We wash with Johnson's soap and washcloths. We put triple dye on the cords but I believe the most recent recommendations say to just leave the cord alone and it will fall off just as quickly, no alcohol or anything. First feed is breastmilk or formula, whichever Mom has chosen, no first feeds of water.

Glucose checks are at 1 hour for anyone who:

1) weighs >4000g or

2) is an infant of a diabetic mothers

3) is less than 37 weeks gestation, regardless of birthweight; or

4) displays symptoms of hypoglycemia.

If that sugar is ok, we don't do any more unless the need arises. If it's between 30-40, Mom breast- or bottlefeeds then we recheck in 30-60min. Under 30, it's more likely that the kid will go to NICU for IV glucose.

Bilichecks: everyone gets one at 24 hours. If that one is ok, they get one on day of discharge. We can do one at any time if they look jaundiced, then draw totals depending on what the transcutaneous result is. Pretermers get a total bili with their PKU draw on DOL 2.

Fyreflie · Oct 18, 2012

When I worked post partum we did our first bath at 8 hours after stable temperatures were documented. First feeds were at breast or bottle and we often asked formula feeding moms if they would consider feeding or even hand expressing colostrum for the first feed or few for the immune and gut benefits--you'd be surprised how many said yes!

Glucose checks: prior to second and subsequent feeds for premature, SGA or LGA babies or GDM controlled by diet or insulin; 30 minutes post first feed + prior to subsequent feeds for type one or two diabetics; or at any point deemed necessary by the RN based on symptomatic presentations.

We continued the checks for 12-36 hours (36 for SGA or insulin controlled diabetics). If a baby was doing really well we would often let peds know and they would let us skip a feed especially for the 36 hour babies to save them some pokes.

We also had a practice if highly encouraging skin to skin for all babies at all times post partum but especially for babies who were not feeding well.

Since there is no established reference range for a "normal" blood glucose for babies under 3 hours old we really tried to keep from doing one prior to that age to minimize interventions based on pediatrician preference.

Bili &PKU screening were done together at 24 hours for SVD with discharge after that bili came back (if it was normal). Sections were 48-72 hours so those babies had both prior to discharge unless they looked jaundiced earlier--metabolic screening is more accurate if you do it later.

Fyreflie · Oct 18, 2012

Oh and we never put anything on our cords at any of the facilities we worked at :)

melmarie23, MSN, RN · Oct 28, 2012

we delay the bath at least the first hour post delivery. I actually will try and delay it until I almost have the infant off recovery (the stable infant that is)...so more at the 2-2.5h mark. We delay it so that mom and baby could get a good amount of skin to skin in, and if breastfeeding, have a good, healthy attempt to get that started.

If there are any potential/suspected sugar issues, such as SGA, LGA, gestational diabetic mother, or symptomatic (and we follow a similar protocol as Elvish on that) we delay the bath until the sugar issue has resolved.

We also wash in a tubby of water, J&J soap and a washcloth. If there is lots of vernix, we will use a soft bristled tooth brush to comb it out of the hair/off the head.

LPI infants will get their first bath somewhere between 12-24 hours post delivery, provided they are stable.

Bili checks are done prior to discharge in the absence of risk factors. With risk factors (ABO incompatibility, Rh incompatibility, poor feeding, LPI, preemie etc), we will do a TCB at the onset or symptoms and/or at the 12-24h mark. Depending on where that falls on the graph, a TSB will be drawn if its high.

Cords we just keep dry. We dont do anything special with them.

PKU heel stick can be done after 24hs of life, but as a practice, we try and do that somewhere at the 48-72h mark. So for our pts we will do the PKU the night before they are discharged to go home...I am night shift, so most of this falls on our shoulders.

NurseNora, BSN, RN · Nov 2, 2012

AWHONN has a monograph on newborn skin care. See their website. Forty some years ago we used water before the first feed to be sure there was no esophageal atresia. Then it was decided we could let breast babies go right to the breast without the water. After a couple years we stoped the water altogether. I haven't seen that order for at least 30 years now.We put nothing on the cord any more (in the past have used triple dye, then alcohol), just keep it open to air and wash with soap and water if it gets poopy.We use Johnson's baby soap for the bath which should be done by 12 hrs. In practice most are done at two hours because L&D doesn't want to "dump" that job on the PP nurses and our moms go to PP at 2 hours. We are in the process of rewriting policy to not bathe earlier than 4 hrs (with exceptions mentioned by a previous poster). Vernix is good for the baby's skin and should be allowed to sink in. Babies nurse better if the first time is before the bath and the smell of the amniotic fluid on the skin is helpful for both mom and baby in the initiation of breastfeeding (no, I don;t have that reference handy, you'll have to search it out). You should be able to get information from the World Health Orginazation about the timing of baths.We do a percutaneous bili reading at 24 hours when we do the PKU and if it;s above a certain level (I do mostly L&D so I don"t remember the number), we draw a serum bili along with the PKU saving the baby an extra stick. Earlier, of course if jaundice is observed.We use the guidelines from APA for glucose checks. See their website.

lovemyjoblandd · Nov 14, 2012

I agree with the things posted here already but I think it is of note to say regardless of time elapsed babies temp needs to be AT LEAST 98.6 prior to first bath. Nothing makes me angrier than getting a cold baby because someone was in a big hurry to bathe it and pass em on. Big big pet peeve. Also we only did tcb on the chest as that proved most accurate for us even though the manufactorer said chest or forehead. If baby was Coombs pos then tcb q12.

PinkNBlue, BSN, RN · Nov 15, 2012

The lady partsl deliveries come up to our nursery within 1 to 2 hours after delivery, usually when mom is transferred. We will do a set of VS and a head to toe and if baby is warm enough, we bathe. C section babies we usually wait an hour, as long as baby is warm, completing 2 sets of VS and a head to toe before. We wash with warm water and Johnson and Johnson, under a radiant warmer.

After the bath, we do cord care by applying bacitracin to the cord once. After the initial application, we leave it dry and instruct the parents to leave it as well.

Feeding depends on mom's choice but usually in L&D, they do skin to skin and then attempt to latch, if breastfeeding is preference for mom. With a c/s, it depends. If mom and baby are stable, the baby will usually stay with mom in recovery to try breastfeeding. If mom is using formula, they will either feed a little in L&D before baby comes to the nursery or bring the baby up, we'll do our admission process and then will go out to mom to feed. Depends on the situation...

Bili levels are drawn by phlebotomy by heel stick 24 hours after delivery, as well as the newborn screen. We have guidelines as to when to notify the pediatrician of a higher result (usually over 7). Each pediatrician has a different level they'll either order a repeat bili level for the next morning, begin supplementation in addition to breastfeeding or initiate phototherapy. Again, depends on the ped.

Our glucose protocol is basically the same thing as Elvish said in her reply. But for babies whose mothers have a hx of GDM, we do an initial blood glucose level and then follow up with 3 AC checks to be certain baby's glucose levels remain stable. Anything below 40, depending on whether the baby is symptomatic, we follow a protocol (either breastfeed and check BG in 30 minutes or formula and recheck in 1 hour).

Hope that helps some! :)

anggelRN · Nov 15, 2012

In my old facility, babies used to be bathed almost immediately. The sole purpose of this was to check off the task so the nurses could move on to other things. Sometimes it would be minutes after delivery and I barely have the bands on when someone is coming in to bathe the baby. Drove me nuts!

babynurse428 · Nov 16, 2012

Thanks everyone! Everything helps!! :up:

labordude, BSN, RN · Nov 20, 2012

Boston Medical Center did a study a short time ago about the effect of delayed bathing on breastfeeding rates. It would seem (and I'm sure this will be replicated) that delaying the bath until around 12 hours has a positive impact on breastfeeding. My hospital (also in Boston, so we have to compete you know) is working on this, instead of "get your warm enough temps and hose'em down!"

Breastfeeding Medicine. October 2011, 6(S1): S-1-S-24. doi:10.1089/bfm.2011.9985.

HeartsOpenWide, RN · Nov 20, 2012

I wait 24 hours for bathing to promote breastfeeding; unless the parents ask for a bath sooner, the kid is covered head to toe with Mec (usually soap on the hair but clean water on body). The only time I do a bath right away without question when stable (with soap head to toe) is if the mom is HIV or Hep C positive.

We do BGs for insulin dependent moms on a 24 hr schedule then PRN. GDM, LGA, SGA, stressed infants, and those with symptoms of hypoglycemia get BG X3 before feelings.

Most of our parents breastfeed, we just stick the kid on the breast, no D5W ( why are you doing that anyway?). If they are going to bottle feed then I do a few CCs of sterile water first; but this is very rare, most of the moms that do rarely bottle feed breastfeed too.

We teach alcohol on cords as well as natural drying