Don't Drop That Baby!

Klein, L. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

NewbornCare

A Pilot Project to Improve Neonatal Peripheral IntravenousSite Assessment and Documentation

Lisa Klein, MSN, RNC-OB,RNC-LRN, CNS, MarymountUniversity, Reston, VA

Keywordsneonatalnursingperipheral intravenousassessmentdocumentation

Paper Presentation

Purpose for the Program

There is currently no consistent protocol de-scribed in the literature for documentation of

the nursing assessment of neonatal peripheral in-travenous sites. Most authors concur that hourlyassessments are the minimum frequency and in-dicate what the assessment parameters shouldbe; however, they do not discuss a protocol fordocumentation of the assessments. Multiple au-thors and professional nursing groups have iden-tified that problems exist in the care of periph-eral intravenous sites in neonates. This projectattempted to determine if nurses in a neonatal in-tensive care unit (NICU) could conduct and docu-ment an hourly evidence-based focused assess-ment of neonatal peripheral intravenous sites.

An additional purpose of the project was to obtaininput from direct care nurses before initiating achange in practice. Critical care nurses performmultiple hourly assessments and care interven-tions on each patient. Additional documentation offive measurement parameters may not be realisticto add to the workload of the direct care nurse. Byhaving the nurses who participated in data collec-tion provide feedback regarding the complexityor simplicity of the instrument, they were able toevaluate the potential value of the process and theinstrument to their care.

Proposed ChangeMany NICUs use a system of charting by excep-tion for assessment of peripheral intravenous sites

in neonates. This project introduced a documen-tation form that includes the five evidence-basedparameters to indicate the status of the peripheralintravenous sites. It attempted to determine if aninstrument on which to document the assessmentwas relevant to the practice of the NICU nursesproviding care. The project also determined thetime needed to perform and document the periph-eral intravenous site assessment and if that timewas considered reasonable by the NICU nursesproviding care.

Implementation, Outcomes, and EvaluationThe documentation form was piloted in a largesuburban NICU. The short-term goal of thispilot project was to determine if the instru-ment on which to document the assessmentand the time to perform and document it wasdeemed reasonable by the nurses providingcare. The nurses are still participating in thepilot project. Early data suggest that the toolmay be helpful but nurses are unsure if all ofthe parameters are necessary for an adequateassessment.

Implications for Nursing PracticeIt is hoped that this project will stimulate furtherstudy of the individual assessment parameters todetermine if any or all of them in a tool format arevalid and reliable in predicting infiltrations and ex-travasations, which would be useful in improvingpatient outcomes.

The Great Pretenders: Utilizing Evidence-Based Practiceto Optimize Clinical Outcomes for the Late Preterm Infant

Jaimi S. Hall, MSN, RNC-OB,Peninsula Regional MedicalCenter, Salisbury, MD

Angela T. Houck, DNPc,RNC-nic, RN-BC, PeninsulaRegional Medical Center,Salisbury, MD

Keywordslate preterm infantevidence-based practice

Newborn CarePaper Presentation


The late preterm infant faces many challengesassociated with prematurity. In 2010, 99 late

preterm infants (approximately 5% of the total birthvolume) were born at Peninsula Regional Medi-cal Center. Nearly 29% of these infants were ad-mitted to the neonatal intensive care unit (NICU),and 12.8% were readmitted to the pediatric unitfor complications associated with prematurity. Thepurpose of this program was to determine if adopt-ing an evidence-based model of care utilizingthe Association of Women’s Health, Obstetric andNeonatal Nurses’ Assessment and Care of theLate Preterm Infant Guideline will improve clinical

outcomes and reduce late preterm infant neonatalintensive care unit admissions and readmissionsto the pediatric unit.

Proposed ChangeTo adopt, institute, and practice Association ofWomen’s Health, Obstetric and Neonatal Nurses’(AWHONN) clinical guidelines for every infantborn between 34.0 and 36.6 weeks of gestationat Peninsula Regional Medical Center.

Implementation, Outcomes, and EvaluationData collection took place over a 6-month pe-riod to determine baseline rates of hypothermia,

JOGNN 2012; Vol. 41, Supplement 1 S31

I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

hypoglycemia, respiratory distress, feeding dif-ficulties, phototherapy, excessive weight loss,neonatal intensive care unit admissions, and read-missions to the pediatric unit. A multidisciplinaryteam developed the late preterm infant initiativeutilizing AWHONN’s clinical guidelines. Compo-nents of the initiative included policy and orderset development, predelivery and predischargeeducation, and individualized feeding plans. Be-ginning March 22, 2011, all late preterm infantswere admitted to the intermediate care nurseryand cared for with a nurse-to-patient ratio of 1:3to 4. All aspects of the clinical guidelines wereutilized based on the individual needs of the in-fant. Data collection on these infants began May1, 2011.

To date, 31 late preterm infants have been caredfor under the new initiative. Eight of these infantswere subsequently admitted to the neonatal inten-sive care unit (25.8%), and no infants were read-mitted to the pediatric unit. The overall goal is toimprove clinical outcomes while reducing admis-sions to the neonatal intensive care unit by 10%

and readmissions to the pediatric unit by 5%, ascompared with the 2010 rates.

Implications for Nursing PracticeAs the primary bedside caregiver, nurses are ex-tremely vested in their patients’ outcomes. Thisinitiative has led to an increased staff awarenessof this population, their unique needs, and thechallenges they face. This knowledge, coupledwith the utilization of evidence-based care, trans-lates into improved clinical outcomes for the latepreterm infant. This initiative also has improvedteamwork and communication and has fosteredrelationships between nurses and other healthprofessionals. Family-centered care is at the coreof obstetric nursing as well as this initiative. Provid-ing care that enhances family bonding, empow-ers parents, and improves clinical outcomes in-creases patient and nurse satisfaction. In this eraof rising health care costs and nonreimbursementfor preventable readmissions, it behooves nursesto adopt practices that anticipate and prevent pos-sible sequelae related to late prematurity.

Tackling Newborn Hypoglycemia in the Delivery Room:Utilizing Colostrum, Skin to Skin and State of the ArtPolicies

Pamela Kinney Tozier, BSN,RNC, CCE, IBCLC, MaineMedical Center, Portland, ME

Keywordshypoglycemiadiabeticshand expressioncolostrumsskin-to-skin



Newborn hypoglycemia in the delivery roomis a widespread challenge. Most often in-

fants who are breastfed and are temporarily sep-arated from their mothers receive formula as aquick fix to increase blood glucose levels. Thisapproach not only decreases breastfeeding suc-cess, but it also exposes the newborn to unsta-ble levels of glucose because of the formula’sstimulation of insulin production. Too many infantswho are breastfed receive excessive amounts offormula within the first hour of life because theirglucose values are checked before feeding, assoon as 15 to 30 minutes after birth. After wit-nessing a 40-minute-old newborn receive 40 ml offormula for a glucose level of 40, then promptlyvomit, gag, and turn dusky, I decided it wastime to act on my concerns that something wasout of balance regarding the blood sugar/feedingissue.

Proposed ChangeTo attain stable glucose levels in babies who arebreastfed by giving infants drops of colostrum,feeding them before labs are checked, and keep-ing them in continuous skin-to-skin contact. I hadrecently become an international board certifiedlactation consultant, and that new level of knowl-

edge, coupled with my nursing experience, pre-pared me well for presenting my ideas to theadministration. I also proposed that we estab-lish ways to give colostrum to babies who werenot ready to latch effectively. I wanted to rewritethe existing breastfeeding policy, have nursesadhere more vigilantly to our skin-to-skin policy,write a policy on prebirth hand expression ofcolostrum, and be a driving force to change manyof the parameters of the newborn hypoglycemiaalgorithm.

Implementation, Outcomes, and EvaluationWe have successfully implemented a new hypo-glycemia algorithm that accepts lower glucosevalues initially, has the newborn feed first, andthen the first glucose level checked by 90 min-utes of age. We have implemented widespreadhand expression of colostrum, before and afterchildbirth, for all of our diabetic patients who arebreastfeeding, and we have maintained continu-ous skin-to-skin contact as a norm. The outcomesto date have been a decrease in separation of themother and baby, higher newborn glucose levels,higher patient satisfaction, and better success ofbreastfeeding.

S32 JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01360.x http://jognn.awhonn.org

Lawson, T. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Implications for Nursing PracticeLabor and delivery nurses are the first line of de-fense in helping stabilize newborn glucose lev-

els without the introduction of formula, thereby up-holding the standard of best practice. It is possiblefor just one nurse with a vision to apply evidence-based practice to achieve quality outcomes.

Premature Infant Nutrition Clinic

Terry Lawson, RN, IBCLC,University of California SanDiego Medical Center, SanDiego, CA

Keywordshuman milkpremature infant nutritionlactation consultant



The benefits of human breast milk for term in-fants outweigh formula. Breast milk is an even

greater benefit to the preterm infant because itprovides infection prevention and promotes im-proved neurodevelopment. In 2006, the Universityof California San Diego Medical Center was desig-nated as Baby Friendly. The Supporting PrematureInfant Nutrition program was launched in 2007.The goal was to improve the growth and nutrition ofpreterm infants. It was noted that following hospi-tal discharge, most mothers were not successfullybreastfeeding their premature infants. These in-fants continued to require fortifiers, but we did notknow how much or for how long. Mothers contin-ued to need to pump, but supply was decreasing.Both parents were exhausted and overwhelmed.

Proposed ChangeIn August 2008, the Premature Infant NutritionClinic was established by a pediatrician and reg-istered nurse. Utilizing a team approach, visits in-cluded infant’s growth and development assess-ments and discussions of the mother’s concerns.After the assessment and discussion, the regis-tered nurse performs a lactation consult and as-sesses the infant feeding, looking for ways to im-prove milk transfer, increase milk supply, and in-crease breastfeeding and decrease breast pump-ing. At the end of the 45- to 60-minute session, aplan is developed to help the mother reach the de-sired goal. Visits are individualized, ranging from

one-time only to several visits 1 to 3 weeks apart. Afollow-up letter is sent to the primary provider withappointment highlights and recommendations.

Implementation, Outcomes, and EvaluationIt was noted during the first year, 97 patients/183visits occurred; the second year, 83 new patients;and the third year, 130 new patients/637 visits oc-curred. During the 3 years, the gestational agebreakdown included the following: 46 newbornsless than 30 weeks of gestation, 90 newborns 30to 33 6/7 weeks of gestation, 104 newborns 34to 33 6/7 weeks of gestation, and 40 newbornsgreater than 37 weeks of gestation. Multiples dataincluded 215 singletons, 83 sets of twins, and 12sets of triplets. Currently, the team sees 7 to 8 pa-tients in a 4-hour session, 1 day a week. There is aneed to expand to 2 days to manage the increasein consultations. Outcomes have improved, suchas increased breast milk for longer duration oftime, more breastfeeding, decreased/no breastpumping, and increased exclusive breastfeeding.

Implications for Nursing PracticeAssuring best practice and performing researchis exemplified by the projects in progress, includ-ing a Premature Infant Nutrition Clinic Quality As-surance project, research of liquid fortification ofthe mother’s milk at discharge, and an interna-tional multicenter validation of a preterm growthchart. Both providers and nurses are involved inevery aspect leading to increased patient and staffsatisfaction.

Implementing Practice Protocols and Education to Improvethe Care of Infants with Neonatal Abstinence Syndrome

Katherine Y. Lucas, DNP,APRN, NNP-BC, Cape FearValley Health System,Fayetteville, NC

Purpose of the Program

The National Council on Alcoholism and DrugDependency estimates that between 1% and

11% of babies born each year are exposed to il-licit substances in utero. The American Academyof Pediatrics reported that 50% to 95% of infantsexposed to opioids or opioid derivatives, includingheroin and methadone, develop neonatal absti-nence syndrome (NAS). Research that is more re-cent describes an increasing incidence of infants

exposed to harmful substances prior to birth. Ba-bies exposed to opioids or opioid derivatives dur-ing pregnancy are at increased risk of developingNAS. Optimal treatment of this NAS population ishampered by the current lack of evidence-basedstandardized guidelines and protocols for phar-macologic management and care that promoteimproved outcomes for NAS patients. Care andmanagement of these infants can be improvedwith practice guidelines and education.



Proposed ChangeTo develop and implement evidence-based clin-ical practice guidelines and an educational pro-

KeywordsNICUFNASTeducation


gram on NAS and the Finnegan Neonatal Absti-nence Scoring Tool (FNAST), to improve nursingassessment and care of the NAS infant, and im-prove scoring accuracy with use of the FNAST.

Implementation, Outcomes, and EvaluationThis study was a nonexperimental, pretest/posttest study that evaluated change in nursingknowledge about NAS and use of the FNAST afterthe implementation of a quality improvement, ed-ucational project. Nurses were tested before andafter participation in education about NAS. A sub-set of 10 nurses was evaluated using the FNASTwith video of infants having NAS. Volunteer par-ticipation in the NAS educational project occurredin 81% of the neonatal intensive care unit nurses.All nurses showed some improvement in scores

on the posttest, with 2% to 44% improvement. All10 nurses who participated in the interactive videotest scored 90% or higher against the FNAST cri-terion 1 week after participation in the educationalproject.

Implications for Nursing PracticeEvidenced-based clinical practice guidelines andeducation on NAS and the FNAST equip care-givers with the necessary tools to consistently andaccurately assess an infant with NAS when usingthe FNAST. Recent research shows that provid-ing education to nurses can result in knowledgegained, improved professional practice, and im-proved patient treatment goals. Education alsocan equip nurses with the necessary knowledgeto care for patients with complex medical prob-lems like NAS. Further, providing nurses withspecific information about a medical problemis correlated with improved adherence to bestpractice.

Perinatal Palliative Care: Support of Mothers,Infants and Families

J. Frances Fusco, MHS, BSN,RN, University CommunityHospital, Tampa, FL

Theresa Bish, RN, IBCLC,University CommunityHospital, Tampa, FL

Keywordsperinatal palliative careinfant advanced directives

Newborn CarePoster Presentation


To support mothers, infants, and familiesthrough the Perinatal Palliative Care program.

Proposed ChangeTo enhance the existing bereavement programto include infants with low viability or no viabilitythrough palliative care.

Implementation, Outcomes, and EvaluationImplementation is in process and awaiting finalapproval of pertinent policies and procedures to

support this program. The evaluation will be basedupon a patient satisfaction survey taken by tele-phone follow-up of patients discharged from thehospital.

Implications for Nursing PracticeProvide care and support to both infants and moth-ers going through this experience.

Neonatal Head Trauma: Implementation of a Care Algorithmto Improve Safety

Sandra Hoffman, MS, RN,CNS-BC, Abbott NorthwesternHospital, Minneapolis, MN


To create a process by which newborns withhead trauma or at risk of complications of

neonatal head trauma are identified, assessed,and monitored differently with the goal of improv-ing safety.

Proposed ChangeTo create and implement a neonatal head traumaalgorithm that is part of the newborn standing or-ders across a large multihospital health systemto ensure that newborns who are at risk of headtrauma or who have head trauma, are evaluatedmore closely to ensure their safety.


Braithwaite, P., Donahue, N. and Bayne, L. E. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Keywordsneonatal head traumavacuum extractionforceps deliverysubgaleal hemorrhage


Implementation, Outcomes, and EvaluationNeonatal head trauma can result in catastrophicoutcomes, and it is essential that infants at riskof complications of a difficult or instrumented de-livery are identified and monitored more closely.Complications, such as subgaleal hemorrhagesmay manifest at birth or may occur over manyhours, so identification of infants at risk and in-creased vigilance is important for patient safety.After a review of the literature, a multidisciplinaryteam of neonatal and birthing clinical nurse spe-cialists, pediatricians, a neonatologist, and aneonatal nurse practitioner created a neonatalhead trauma algorithm to become part of the new-born standing orders. Staff and physician educa-tion was done regarding neonatal head trauma,

and the neonatal head trauma algorithm was im-plemented across a large multihospital health sys-tem. The evaluation of this change is ongoing.

Implications for Nursing PracticeNurses caring for newborns are in a key positionto identify complications of neonatal head traumathat may result from the birthing process. A stan-dardized approach can ensure the identificationand closer monitoring of infants who may have aninjury that may not manifest for many hours afterdelivery. Education about neonatal head traumaincreases awareness of the risks, promotes ap-propriate pain management, and helps to keepnewborns safe.

Help! I’m Cold! Improving the Warmth of Our Newborns

Pamela Braithwaite, BSN,RNC, Christiana Care HealthSystem, Bear, DE

Nicole Donahue, BSN, MSN,RNC, Christiana Care,Middletown, DE

Lynn E. Bayne, PhD, NNP-BC,RN, Christiana Care HealthSystem, Newark, DE

Keywordspretermhypothermiafishbone diagramroot-cause analysismorbiditymortalitypolyethylene



Cozy Cuties is a multidisciplinary performanceimprovement team convened to address hy-

pothermia from birth to admission to the neona-tal intensive care unit among inborn preterm in-fants at less than 31 weeks gestational age. Re-view of facility data over the past 5 years showedthat the initial admission temperatures of theseinfants were significantly lower than average inour neonatal intensive care unit (NICU) than thebenchmark of 850 NICUs within the Vermont Ox-ford Network. Across this time period, 61% of theinfants who were less than 31 weeks gestationalage had body temperatures less than 36◦C at ad-mission and were classified as hypothermic usingthe World Health Organization definition. Two largestudies of infants from 23 weeks to 30 completedweeks of gestation, suggested that when infantsare admitted to the NICU with hypothermia, theirchances of survival decrease by approximately10% for every degree below 36◦C, independentof any disease conditions. In addition, late onsetsepsis is increased by 11% and odds of death areincreased by 28%.

Proposed ChangeRoot cause analysis using fish bone techniqueswas conducted on the first five cases of ad-mission of hypothermia for each calendar monthover the 12-month period prior to project incep-tion. Literature was reviewed to establish potentialcauses. A facility tour determined how many po-tential causes existed and coupled the potentialcause with evidence-based interventions. A ther-

mal intervention bundle was developed and im-plemented. The bundle included a timeout-stylethermal checklist, increased room temperature,proper radiant warmer preheat and use, short-ened infant time at point of delivery for both vagi-nal birth and cesarean birth, change in transfertechnique of newborn to a warmer from point ofdelivery, effective use of polyethylene wrap, at-tention to application of pulse oximetry, warmingof surfactant, and warming of caregiver hands.Aggressive clinical staff education in labor anddelivery and NICU was conducted using a vari-ety of methods, including video and social media.Post-implementation, infants who were less than31 weeks gestational age were prospectively fol-lowed and the incidence of the outcome variableswas collected.

Implementation, Outcomes, and EvaluationData were analyzed, and findings showed that ouradmission hypothermia rates have been reducedfrom 61% over the past 5 years to approximately18% over the past 6 months. Ongoing monitoringfor sustained improvement is now in place.

Implications for Nursing PracticeA multidisciplinary team can be an extremely ef-fective agent of change. It is important to bringkey stakeholders in a project to realize gains. Clin-icians are obligated to benchmark practices thatmay contribute silently to patient illness. Body tem-perature should never be taken for granted. Thegoal should always be to keep a warm infant warm,not to rewarm a cold infant.



Welcome Aboard and Homeward Bound: The NICUFamily’s Journey for a Safe Voyage to Discharge

Geraldine Tamborelli, MS, RN,Maine Medical Center,Portland, ME

Keywordsdischargesatisfactionbest practiceeducationfamily centered caremultidisciplinary



Improve parent and staff satisfaction with the dis-charge process and complex follow-up care for

the very premature or sick infant. Involve parentsin the plan of care, the daily care of their infants,and their personal preferences early on.

Proposed ChangeTo standardize teaching, timing of education, doc-umentation, and communication of education tobetter prepare parents for discharge.

Implementation, Outcomes, and EvaluationImplementation using Plan-Do-Study-Act cycles,staff and patient satisfaction, as well as chart au-dits were used for measurement and feedback.

Implications for Nursing PracticeThe best practice was identified and we continueto maintain the gains by evaluating satisfactionlevels and random chart audits.

Birthways Lactation Services: A Modelfor Breastfeeding Support

Angela Carswell, RN, IBCLC,Mary Greeley Medical Center,Ames, IA

Keywordslactation programexceeding national and state

breastfeeding rates



The purpose of the Birthways Lactation Ser-vices program is twofold. We want to increase

breastfeeding initiation and duration rates andthereby improve long-term health for every infant.We also want to increase the lactation consultant’sproductivity while decreasing full time equivalentsand cost. Most lactation programs have lost statefunding in recent years and are now funded byhard-to-find grants, or as in our hospital’s case, bycommunity benefit dollars.

Proposed ChangeFor 10 years, our program was set up to providehome visits to our clients (within a 50 mile radius)who either chose to have a visit or when a visit wasphysician ordered. Eight years ago, it was deter-mined this was a costly way to deliver care evenwith funds provided by a grant and some insur-ance reimbursement. At that time we started theclinic model and were encouraged by the pos-itive results. Our lactation consultants cross-trainto the discharge planning position of the BirthwaysLactation Services program where they round withthe pediatricians, schedule the clinic visits at dis-charge, and provide a discharge feeding plan forbabies with feeding problems.

Implementation, Outcomes, and EvaluationThree to five times per day, the coordinator of thelactation program and her team perform checks

that include weight, jaundice, and lactation evalu-ation. We believe our outcomes reflect the successof the program. Our breastfeeding initiation rate is87.6% as compared with the state’s 73.9%. Our6-month breastfeeding rate is 79.3% (one of thebest in the state) as compared with the nationalrate of 17%. We are ahead of the Healthy People2020 goals of an 81.9% initiation of breastfeedingand a 6-month breastfeeding duration of 60.6%.Our home visit model took 3.1 full time equivalents,and our clinic model takes 1.2 full time equivalents,which represents a savings of more than $140,000in salaries and mileage reimbursement. Our lacta-tion consultants can see five more infants per dayor 25 more per week, which makes it possible toprovide second visits for those clients who needthem.

Implications for Nursing PracticeThe advantages of breastfeeding are well re-searched and well documented. We believe ourprogram model is the best practice and is leadingthe way in breastfeeding promotion and support ofthe American Academy of Pediatrics Policy State-ment and the U.S. Surgeon General’s Call to Actionto Support Breastfeeding. Our service model de-creases hospital readmission rates and promotesexclusive breastfeeding with increased productiv-ity and decreased cost.


Keller, A. and Brenneman, A. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Operation Kangaroo Care

Anne Keller, MS, RNC, CNP,OhioHealth, Columbus, OH

Alicia Brenneman, BSN, RNC,Grant Medical CenterOhioHealth, Columbus, OH

KeywordsKangaroo Carecesarean birth



Kangaroo care is recommended in the Guide-lines for Perinatal Care for stable newborns.

The act of placing the infant skin-to-skin (alsocalled Kangaroo care) with the mother has beenshown to maintain skin temperature regulationof the newborn, increase initiation of successfulbreastfeeding, and ease the transition for intrauter-ine to extrauterine life. The practice of Kangaroocare has been well adopted in our setting. During2010, 75% of all mothers who gave birth vaginallyparticipated in skin-to-skin care. The staff startedto initiate Kangaroo care in the postanesthesiacare unit to provide all the benefits to the moth-ers who had cesarean births.

Proposed ChangeBefore the initiation of skin-to-skin in the postanes-thesia care unit, infants had been removed fromthe warmer after being wrapped with warm blan-kets and a hat and given to the mother to holdor breastfeed. This process was not satisfying tothe staff. The staff stated that if the vaginal birth in-fant could benefit from skin-to-skin, then we shouldadopt the practice with the cesarean birth infant.

The process before leaving the operating room isto now initiate skin-to-skin with the infant (who isdressed only with a diaper and hat) and applywarm blankets against the back of the infant whileleaving its chest exposed.

Implementation, Outcomes, and EvaluationThe implementation was started by staff nurseswho considered the evidence-based practice ofKangaroo care to be best for the newborn. Staffbegan by placing the infant skin-to-skin after mov-ing the mother from the operating room tableto a hospital bed. Both are transported to thepostanesthesia care unit, initial checks are pre-formed, and a baseline set of vitals is obtainedon the infant. The mother-infant pair is left skin-to-skin for the next 60 to 90 minutes. Outcomeshave been measured by patient satisfaction andstable infant temperatures during the time frame.Patients report they would initiate Kangaroo carewith their next birth.

Implications for Nursing PracticeEmpowering nurses to change practice to over-come traditional barriers of medical care to pro-mote the empowerment of motherhood.

Infant Feeding Plan: An Innovative Documentation Tool toImprove Communication between Caregivers and Families

Jennifer Peterman, RN, BSN,IBCLC, Hospital of theUniversity of Pennsylvania,Philadelphia, PA

Keywordsbreastfeedinginfant feeding planpatient–family centered care



A lack of communication was identified sur-rounding a mother’s feeding decision and

multiple health care providers. This lack of com-munication resulted in a mother’s perceived lack ofrespect by providers regarding her preference fornewborn feeding. To address this issue, an innova-tive, crib side, infant feeding plan documentationtool was created to identify a mother’s preferencefor feeding her newborn from birth through dis-charge. Providers also noted a large variation be-tween provider practices related to newborn feed-ing and maternal preference.

Proposed ChangeTo improve communication between providersand mothers, a crib side infant feeding plan doc-umentation tool was implemented.

Implementation, Outcomes, and EvaluationPrior to implementation, representatives from eachprovider group involved in newborn care collab-orated on the creation of the infant feeding plan

document. The development of the individualizedplan began at maternal admission, with the use ofa scripted narrative, to discuss maternal newbornfeeding preferences. Once feeding preferenceswere identified, a mutually agreed upon feedingplan was created and signed by both the motherand the nurse. Throughout the infant’s stay, theplan was located at the infant’s crib. If any changesto the feeding plan were needed, both the nurseand mother discussed, updated, and signed therevised feeding plan.

Outcomes and evaluation are ongoingPrior to the implementation of the feeding plan,breastfeeding rates were 68% and during the yearpostimplementation, breastfeeding rates havecontinued to increase to 74%. Anecdotally, pa-tients report feeling that their infant feedingchoices are respected and that the use of this planprompts infant feeding discussions. Providerscommented that the plan is convenient and usefulin practice, and the Joint Commission recognizedit as a best practice model of care.



Implications for Nursing PracticeThis initiative provided an opportunity for nursingto re-energize their commitments to patient com-munication and infant feeding, especially breast-feeding. Patient–family centered care is basedon respect and honest communication betweenproviders and families. This tool gave nurses anopportunity to dialogue with the infants’ mothers

regarding feeding options and changes in infantfeeding as needed. At admission, nurses wereable to review with the family the evidence asso-ciated with optimal infant feeding. Also, the toolserved as a contract between the mother andthe providers to ensure that the mother’s feedingpreference plan was implemented. The tool alsoserved as an easy way to communicate to anyprovider caring for the infant.

A Baby Weigh Station: Continuum of Care for Late PretermBreastfeeding Infants

Kathleen H. Bright, BSN,RNC, IBCLC, DoctorsHospital-Ohiohealth,Columbus, OH

Joyce Sheppard, RN, IBCLC,Women’s Health Services,Riverside Methodist Hospital,Columbus, OH

Whitney Lenger Mirvis, BSN,RN, IBCLC, RiversideMethodist Hospital, Columbus,OH

Jane Lamp, MS, RN-BC, CNS,Riverside Methodist Hospital,Columbus, OH

Keywordslatepretermbreastfeedingweigh



Late preterm infants who breastfeed are thelargest segment of preterm infants. In Colum-

bus, Ohio, the incidence of late preterm infantswho breastfed was 9.1% of live births (in 2008)and the rate at our hospital was 7.7% (of 6,456births/year in 2010). Late preterm infants often ap-pear to be able to breastfeed successfully duringhospitalization, (hence, their nickname “the greatimposter”), but this may not be sustained follow-ing discharge. As 1 of 15 sites for the Associ-ation of Women’s Health, Obstetric and Neona-tal Nurses’ 2010 Late Preterm Infant Evidence-Based Practice Guidelines research study, com-mitment occurred in this hospital’s outpatient set-ting to measure and improve post-discharge careof late preterm infants who breastfed.

Proposed ChangeTo ensure a successful continuum of care for thepostdischarge late preterm infant via a commu-nity resource where 90% of late preterm infantswill gain weight after events of lactation consulta-tion and first weight measurement.

Implementation, Outcomes, and EvaluationUtilize a baby weigh station within a user-friendlylactation support center to offer a community ac-cessible onsite, free service, monitored by ap-

proachable staff and expert professionals. Identifylate preterm infants who return for repeat weightmeasurement, track weight gain, and generatemonthly progress reports. To estimate the totalnumber of late preterm infants who were consultedand weighed on more than one visit, the followingformula was used: Numerator – number of latepreterm infants who gain weight of more than 0.5ounces at more than 5 days of age and thereafter;Denominator – total number of late preterm infantsconsulted/weighed. Over 12 months, 151 individ-ual late preterm infant weights were measured:116 had repeated weights and 99% demonstratedweight gain (monthly averages). Additional bene-fits included referrals to lactation, pediatrics, pe-diatric surgery, and behavioral services. An ac-cessible weigh station was evaluated to be an ef-fective pathway to ongoing care and support forlate preterm infants. Late preterm infants gainedweight appropriately and their mothers reportedsustained breastfeeding.

Implications for Nursing PracticeAccessible community service, monitored by ap-proachable staff and expert professionals is aneffective means to continue and grow client re-lationships. Monitor at-risk groups for anticipatedproblems and provide a portal for continuing care.


Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Increasing Exclusive Breast Milk Feeding Rates at an UrbanAcademic Hospital

Laurie Dohnalek, RN, MBA,NE-BC, Georgetown UniversityHospital, Washington, DC

Cynthia Heer, RNC-OB,RN-BC, MSN, GeorgetownUniversity Hospital,Washington, DC

Elizabeth Starrels, RN, BSN,IBCLC, Georgetown UniversityHospital, Washington, DC

Carol A. Ryan, MSN, RN,IBCLC, FILCA, GeorgetownUniversity Hospital,Washington, DC

Margaret Howland, RN, BSN,RNCOB, GeorgetownUniversity Hospital,Washington, DC, DC

Lauren O. Wurster, RN, MSN,Georgetown UniversityHospital, Washington, DC

Keywordsexclusive breastfeedingexclusive breast milk feedingbreastfeeding ratesJoint Commissionperinatal core measure



To increase exclusive breast milk feeding ratesat an urban academic hospital.

Proposed ChangeOver an 18-month period interventions were imple-mented to increase exclusive breast milk feedingrates by at least 10%.

Implementation, Outcomes, and EvaluationTo implement this program, the following interven-tions were completed:

� Creation and implementation of Donor Pas-teurized Milk Policy; all nurses attendedmandatory education session

� Implementation of 24-hour rooming in (noseparation of mothers and newborns via stan-dard nursery)

� Survey given to patients to identify the mostpopular reasons for supplementation

� Journal clubs discussing breastfeeding is-sues

� Consultations with lactation consultants atother facilities

� Increasing rates and duration of initial skin-to-skin contact and first breastfeeding session

� Daily patient rounds and assessments by in-ternational board certified lactation consul-tant

� Mandatory interdisciplinary breastfeedingeducation for all nurses, obstetricians, andpediatricians

� Education related to alternative breast milkfeeding methods

� Outside speaker (international board certi-fied lactation consultant) that moderated dis-

cussion of obstacles to exclusive breast milkfeeding

� Feeding care plans (for complicated situa-tions) developed collaboratively with nursesand international board certified lactationconsultants

� Implementation of mother and newborn“quiet time”

These interventions were implemented and the re-sult was an increase in the staff’s knowledge andskills, thus changing practice and creating confi-dence. The outcome was that our exclusive breastmilk feeding rates increased. A data collection toolwas created to monitor and track exclusive breastmilk feeding rates. We also are utilizing a patient-based survey to evaluate the effectiveness of theinterventions.

Implications for Nursing PracticeEducation is a major aspect of our initiative to in-crease exclusive breast milk feeding rates. Thelow incidence of exclusive breastfeeding is par-tially due to a lack of breastfeeding knowledgeamong health care professionals. Educational pro-grams that increase nurses’ knowledge and im-prove attitudes toward breastfeeding promote ac-curate and reliable delivery of breastfeeding infor-mation and skills to the mothers. These programsalso encourage positive role modeling of support-ive breastfeeding attitudes. This may improve ex-clusive breast milk feeding rates because of theeffect that this has on patients. Many of the in-terventions included in our program are directlyaimed at increasing breastfeeding knowledge ofour staff and patients.

Exclusive Breastfeeding: “It Takes Our Village”

Julie Delcasino, RNC-MNN,BSN, Presbyterian Healthcare,Charlotte, NC

Diane Slough, RN, BSN,IBCLC, Presbyterian Hospital,Charlotte, NC

Keywordsexclusive breastfeeding



Exclusive breastfeeding is best for the infantand mother. Evidence-based practice de-

scribes this choice, but who can say their hospitaltruly promotes exclusive breastfeeding? We are a600-bed hospital with more than 7,000 births/year.It takes our village to educate the mother, fam-ily, and staff within women’s services. It is the re-sponsibility of us all to help mothers be successfuland promote the recommendations of the Asso-ciation of Women’s Health, Obstetric and Neona-tal Nurses, World Health Organization, AmericanAcademy of Pediatrics, American College of Ob-

stetricians and Gynecologists, U.S. Department ofHealth and Human Services, Centers for DiseaseControl and Prevention, and the Joint Commissionfor exclusive breastfeeding.

Proposed ChangeWe want to provide best patient care. In May2010, our exclusive breastfeeding rate was 37%.We realized our shortfall and discussed ways toimprove our rate. Within our shared governancestructure, we have a unit research council. Thetopic of change regarding exclusive breastfeed-ing, hospital supplementation, and education for



staff was our new project. Our council consists ofstaff nurses from the departments of mother–babyand gynecology. The nurse educator and lacta-tion consultant are also committee members. Webegan with a literature search. How do you treata baby with low blood sugar but still exclusivelybreastfeed? What do you do when a mother ismedically unable to breastfeed after birth? Whatabout mothers who want to sleep all night andrequest that staff bottle feed their infants? Whatabout the obstetrician or pediatrician who tells themother, “You need your sleep at night. A little for-mula never hurt.” What about labor and deliverynurses who say, “Breastfeeding is not our job, it’sthe lactation consultant’s job.” Extensive educa-tion was needed for women’s services staff, physi-cians, parents, and families.

Implementation, Outcomes and EvaluationThe nurse educator and lactation consultant de-veloped an education program for all women’sservices staff. The major health care organizationsthat recommended exclusive breastfeeding were

cited. Articles from the literature search were pre-sented. Benefits of breastfeeding for the mother,infant, and community were discussed. Many ex-amples of hospital practices that decrease suc-cess of exclusive breastfeeding were recalled.Skin-to-skin care and rooming in were discussed.In North Carolina, we have the Perinatal Qual-ity Collaborative of North Carolina for exclusivebreastfeeding. The Perinatal Quality Collaborativeof North Carolina’s well-baby track focuses onsupporting mothers’ choice to provide exclusivebreastfeeding for their term infants. We becamean active member of the Perinatal Quality Col-laborative of North Carolina project for exclusivebreastfeeding.

Implications for Nursing PracticeWe want to provide the best practice and the litera-ture supports exclusive breastfeeding. As obstet-ric nurses, we have power to educate and supportmothers and families to make informed decisionsabout their individual infant’s care.

Now I Lay Me Back to Sleep . . . .Safely

Courtnie J. Burrell, RNC,Henrico Doctors’ Hospital,Richmond, VA

Diane Stairs, RN, HenricoDoctors’ Hospital, Richmond,VA

KeywordsSIDSsafe sleepmodel



One of the Healthy People 2020 goals is to im-prove the health and well being of women,

infants, children, and families. One way to accom-plish this goal is by reducing the rate of fetal andinfant deaths. In Virginia, from 2003 to 2007, therewere approximately 78 infant deaths/year due tosudden infant death syndrome (SIDS). This rateis greater than the national average. It has beenproven that supine sleeping is the greatest fac-tor in reducing the risk of SIDS even though manynurses still feel more comfortable placing the babyprone. Hospital nurses are the first professionalrole models for new parents. Modeling suggestedbehaviors, such as back sleeping, can be a pow-erful education tool as well as parental educationthrough verbal and written educational materials.

Proposed ChangeInfants are no longer able to have stuffed animalsor extra blankets in the incubator or crib. Oncethe infant is transitioned to an open crib, the infantshould be placed in a supine position unless aphysician’s order indicates otherwise. Nurses areto model safe sleep positioning at least 24 hoursprior to discharge and provide parental educationon SIDS and SIDS risk reduction. SIDS educationis also offered at infant cardiopulmonary resusci-tation classes.

Implementation, Outcomes, and EvaluationThe safe sleep task force was initiated and a hos-pital policy on safe sleep was written. The staffreceived mandatory in-services regarding SIDS toensure consistency in parental education. One in-service was on SIDS and SIDS risks in the termnewborn and the other addressed the needs of thepremature infant. Safe sleep education was addedto the March of Dimes notebook, which all parentsof infants admitted to the neonatal critical carecenter receive. This is reviewed with the parentsprior to discharge. An education record is signedat discharge acknowledging that the informationwas reviewed. After discharge the charts areretrospectively audited for safe sleep educationand supine positioning at least 24 hours prior todischarge.

Implications for Nursing PracticeThe expectation is to provide consistent safe sleepeducation to the parents and to model safe sleeppositioning. Data collected will be used to validatesuccess of the program and to encourage the staffcontinued participation and support. Integratingevidence-based findings into practice will facili-tate further involvement into addressing the higherincidence of sudden infant death syndrome in theAfrican American population.


Dohnalek, L., Heer, C., Starrels, E., Ryan, C. A., Howland, M. and Wurster, L. O. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Implementing Skin-to-Skin Care in a Baby-FriendlyCommunity Hospital

Jennifer L. Reeg, MSN, RNC,Health First Cape CanaveralHospital, Cocoa Beach, FL

Tracy Lott, RNC, BSN, MS,Health First Cape CanaveralHospital, Cocoa Beach, FL

Keywordsbreastfeedingskin-to-skin carekangaroo carenewborn



To improve mother–infant attachment andbreastfeeding.

Proposed ChangeTo implement skin-to-skin care in a baby friendlycommunity hospital.

Implementation, Outcomes, and EvaluationHealth First, Inc. Cape Canaveral Hospital, aBaby-Friendly facility since June 2000, launched askin-to-skin initiative in 2009. An evidence-basedpractice protocol for placing newborns skin-to-skin at birth and in the immediate postpartum pe-riod was incorporated into our labor, delivery, re-covery, and postpartum (LDRP) unit, and encour-aged during the entirety of the postpartum stay.Staff nurses were educated in appropriate skin-to-skin techniques and patient instruction, first in asmall group interactive setting and later followedwith a video and discussion format. Patient ed-ucation pamphlets were distributed to women inlabor and Kangaroo care shirts were loaned tonew mothers during their hospital stay. Familieswere encouraged to attempt to keep their new-born skin-to-skin for up to 6 hours a day for the firstweek of life and a minimum of 2 hours a day for thesecond week through fourth week. Mothers wereassured that anyone, e.g., fathers and grandmoth-ers, can engage in the skin-to-skin care with theinfant. Studies have reported benefits of skin-to-skin care of the newborn to include reduced cry-ing, improved mother–infant interaction, warmerbabies, and greater breastfeeding success. Ad-

ditional positive effects on neonatal self-regulationduring the transition from intrauterine to extrauter-ine life include increased sleep, decreased apneaand bradycardia, improved respiration and oxy-gen saturation, accelerated weight gain, and, forthe mother, increased milk production. The staff atCape Canaveral Hospital has observed anecdotalevidence of these benefits.

The nursing and lactation staff at Cape CanaveralHospital strive to achieve skin-to-skin care with ev-ery new mother–baby couplet, making allowancefor individual circumstances and infant condition.A chart audit was conducted from 2010 to 2011for evidence of skin-to-skin care attempted andencouraged immediately after birth and within thefirst hour of life, and of documentation of mothereducation on benefits of skin-to-skin care. Resultsshow a 90% success rate, indicative of a positivetrend in the number of mother–baby couplets opt-ing for this practice and verbalizing their intent tocontinue skin-to-skin care at home. Mothers seenone-on-one in the lactation clinic after dischargeare further encouraged to continue skin-to-skincare in the first weeks.

Implications for Nursing PracticeThe practice of skin-to-skin care as a componentof our baby friendly philosophy contributes posi-tively to neonatal transition, enhances attachment,and promises long-term benefit to new families.We at Cape Canaveral Hospital are committed tocontinuing promotion of skin-to-skin care as partof best practice.

Cue-Based Feeding: Implementation in an 83 Bed, LevelThree, Metropolitan Neonatal Intensive Care Unit

Lindsay Newland, RN, BSN,IBCLC, Baylor UniversityMedical Center Dallas, Dallas,TX

Keywordscue based feedinginfant driven feedsNICUfeeding



The purpose of this program was to implementcue-based feeding in our neonatal intensive

care unit (NICU).

Proposed ChangeAchievement of full oral feedings is often timesthe last milestone reached prior to dischargefrom the NICU. Many NICUs still used a sched-uled feeding method to initiate and progress oralfeedings. Several studies have come out to sup-port that a cue-based feeding approach, alsoknown as an infant-driven approach, may help

the NICU infant achieve full oral feedings up to6 days sooner than a scheduled feeding method.A cue-based feeding approach tailors the pro-gression of oral feedings for each individual, withclose attention paid to the infant’s developmentalcues to decrease stress. The following outlines ourtransition from scheduled feedings to cue-basedfeedings.

Implementation, Outcomes, and EvaluationWe introduced a cue-based feeding program inour 83-bed, level three, metropolitan NICU, whichhas more than 200 nurses and staff. This was



achieved with a multidisciplinary team approach.Staff education was given by nurses, includingone team leader and four super-trainers on eachshift. Education was given in the form of bedsidein-services, updates in the unit newsletter, a nurs-ing policy and guideline, and a continuing educa-tion offering. The education ranged in topics, suchas benefits of cue-based feeding, how to read in-fant cues, how to use a cue-based feeding scaleform, educating parents, and trouble shooting. Af-ter implementation, bedside charts were auditedto assess staff adherence with cue-based feed-ing and address issues. Concerns and commonissues were addressed in the form of bedside

in-services, questions and answers, updates inemails and newsletters, as well as focus groups oneach shift. A multidisciplinary meeting took place 6months after implementation to address concernsand update the program.

Implications for Nursing PracticeCue-based feeding has become a common lan-guage in our unit and is considered a success.Research is currently underway in our unit to as-sess time to full oral feedings and the effect ondirect breastfeeding rates. Future research to con-sider is the effect that cue-based feedings has onoral aversion after discharge.

Be Quiet! You Are Getting On My Neurons! NoiseReduction in the Neonatal Intensive Care Unit

Jennifer L. Notestine, BSN,RNC-NIC, Mount Carmel EastHospital, Columbus, OH

Teresa L. Rapp, RN, NNP-BC,Mount Carmel East Hospital,Columbus, OH

Keywordsnoiseneurodevelopmentneonateneonatal intensive care unit



Multiple studies have shown that excessivenoise affects neurodevelopment in infants.

Our clinical excellence committee wanted to ex-plore the noise levels in our neonatal intensivecare unit (NICU). Our findings were that our levelsexceeded recommended levels. Based on thesefindings, we felt that changes needed to be made.

Proposed ChangeWe provided education on the effects of excessnoise on neonates to our NICU staff and imple-mented noise-reduction strategies in an attemptto decrease our overall noise level.

Implementation, Outcomes, and EvaluationOur clinical excellence committee presented edu-cation on the effects of excess noise with the sup-

port of the hospital leadership. Education includedpresentations in unit meetings as well as posterpresentations. Specific noise-reduction strategieswere proposed by the clinical excellence commit-tee and agreed upon by the staff. Strategies wereimplemented by the staff and follow-up monitoringwas completed to assess effectiveness.

Implications for Nursing PracticeResearch has shown that the immediate effectsof elevated levels of sound show that environ-mental noise can be a major source of stressfulstimulation, can cause agitation, and bring aboutcomplications in the medical management of theneonate. Heightened awareness of the effects ofnoise in the NICU promotes an optimal environ-ment for positive developmental outcomes.

Exploring New Frontiers: Providing Skin-to-Skin Contactfor Mothers and Newborns during Cesarean Birth

Nora C. Fortin, RNC-OB, BSN,Wentworth Douglass Hospital,Dover, NH

Keywordsskin-to-skinpatient satisfactionneonatal thermoregulation



As cesarean birth rates increased in the UnitedStates in response to the American Col-

lege of Obstetricians and Gynecologists’ state-ment concerning vaginal birth after cesarean,studies demonstrated higher dissatisfaction withchildbirth experiences. Women giving birth by ce-sarean are more prone to postpartum depression,bonding difficulties, and unsuccessful breastfeed-ing.

Proposed ChangeTo increase maternal delivery satisfaction, we de-veloped a plan to provide skin-to-skin contactimmediately after cesarean births. The proposedchange broke the barriers between the traditional

surgical environment and the delivery room andrequired collaboration between the departmentsof surgical services, anesthesia, pediatrics, andobstetrics.

Implementation, Outcomes, and EvaluationInformal surveys of patient satisfaction since im-plementation have been positive. A more formalevaluation of the process will include a review ofnewborn thermoregulation in the operating roomand a postpartum survey of patient satisfaction.

Implications for Nursing PracticeThis new service is an example of how nurses areempowered to question tradition to advocate fortheir patients.


Fortin, N. C. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Mom’s Own Milk Bundle: Increasing Supply in an 83 Bed,Level III, Neonatal Intensive Care Unit

E. Christina Conner, BSN, RN,IBCLC, Baylor UniversityMedical Center at Dallas,Dallas, TX

Keywordsbreast milkNICUquality initiativescollaborativeincreasingmilk supply



Hospitals are encouraged to step upevidence-based practices with various ini-

tiatives, such as The Joint Commission PerinatalCore Measures and Baby Friendly Hospital Ini-tiative, which both recognize the protection andvalue of mom’s own milk. The use of human donormilk in the neonatal intensive care unit (NICU) hasbeen expensive but worth the payoff with lessvery low birth weight morbidity and mortality inour large NICU. The purpose of the Mom’s OwnMilk (MOM) Bundle is a multidisciplinary, collabo-rative approach to gently encourage and supporta mother’s decision to provide her precious milkfor her baby in the NICU.

Proposed ChangeThe MOM Bundle uses quality initiatives through-out the Women and Children’s Service line to ini-tiate and maintain the mother’s milk supply. Im-provements are focused on the barriers mothers

face when providing milk and discovering an in-novative game plan to reduce those barriers.

Implementation, Outcomes, and EvaluationImplementation of this quality initiative focuses onstaff and family education. After looking at theaverage length of stay, baseline breastfeedingrates, number of donor milk bottles used eachday, and fiscal expenditures spent on donor milk,our goal is projected to decrease donor milk use,decrease medical and surgical necrotizing ente-rocolitis rates, and decrease length of stay.

Implications for Nursing PracticeThe MOM Bundle is a collaborative approach toincrease the availability and volume of mothers’milk in our Level III, 83-bed, NICU. Working to-gether with our medical, nursing, and NICU sup-port staff, we project an increase in mom’s ownmilk, which benefits the mother, the infant, and thehospital goals.

Virtual Special Care Nursery: A Cost Savings Idea

Michelle M. McFail, MSN,RNC-OB, Baptist Health, LittleRock, AR

Keywordsspecial carelength of staylate preterm infant



The purpose of the virtual special care nurs-ery is to decrease the length of stay for these

patients while maintaining quality care.

Proposed ChangeA majority of infants born 35 to 36 6/7 weeks ofgestation and infants born to mothers who werediabetic and insulin-dependent were admitted tothe neonatal intensive care unit (NICU) for monitor-ing within 24 hours of birth. The average length ofstay for the special care infant was 7 days. It wasdecided that the differing needs of these infantsfrom full-term newborns could be provided for ina virtual setting. Nurses would be trained follow-ing evidence-based guidelines. The care wouldbe provided in the mother’s room or the well-babynursery.

Implementation, Outcomes, and EvaluationOver a 6-month timeframe, information was gath-ered, equipment purchased, protocols estab-lished, and a plan was implemented to care forthe special care infant on the postpartum unit. The

team estimated that within 24 hours after birth,approximately 75% of late preterm infants wereadmitted to the NICU prior to the implementationof the special care nursery. After 6 months of im-plementation, the admissions had decreased to9%. Each year since implementation, the numberof admissions to the NICU has decreased for thispopulation. The length of stay has decreased from7 days to approximately 2 days for this group aswell.

Implications for Nursing PracticeNursing staff in the special care nursery aretrained to evaluate and intervene quickly basedon evidence-based protocols. This allows for theinfant to remain with the family. Having the in-fant in close proximity increases the time avail-able for educating the mother about the uniqueneeds of the special care infant and allows herto feel an increased sense of confidence whentaking the infant home. This process increasesthe nursing staff’s satisfaction about the care theyprovide.



Two Phase Innovative Approach for Newborns at Riskof Hyperbilirubinemia

Martha Montes, BSN, RN,University of Illinois MedicalCenter, Chicago, IL

Lourdes Notario, BSN, RN,University of Illinois MedicalCenter, Chicago, IL

Keywordshyperbilirubinemiaphototherapytranscutaneous bilirubin (Tcb)Bili clinic



Each year approximately 60% of the 4 mil-lion newborns in the United States receive

a diagnosis of clinical jaundice. The American ofAcademy of Pediatrics has instituted guidelinesfor the assessment and management of hyper-bilirubinemia in newborns. The purpose of thisproject was to develop an innovative approachto identify newborns at risk of hyperbilirubinemiaat delivery and at 24 hours of life and to improveneonatal outcomes for at-risk infants with hyper-bilirubinemia after discharge during the weekendand holiday. Most infants with hyperbilirubinemiawho are discharged before 72 hours should beseen within 2 days of discharge.

Proposed ChangePreviously, discharged infants with hyperbiliru-binemia who required follow-up on weekends andholidays were seen in the emergency room, whichdelayed evaluation and treatment. We sought toidentify infants at risk and streamline the evalua-tion and treatment process by instituting a week-end and holiday Bili Clinic on the mother-babyunit.

Implementation, Outcomes, and EvaluationTo identify infants at risk, we instituted collectionof cord blood type and Coombs testing at deliv-ery for mothers with blood type O positive or RHnegative blood types. Furthermore, all newbornsafter 24 hours of life had a transcutaneous biliru-

bin test performed and if the result was greaterthan 6 a serum bilirubin specimen was collected.The goal was to identify those at risk of hyper-bilirubinemia and initiate treatment in a timely man-ner. The weekend and holiday Bili Clinic openedin April 2010. During the week, newborn healthcare providers (from the departments of pediatricsor family medicine) identified newborns requiringoutpatient follow-up on the weekend and holidayand initiated the process for pre-admission to theBili Clinic, maintained a logbook, and informedparents of required follow-up. Parents received aninformation form with the follow-up appointmentto the Bili Clinic (scheduled anytime from 8:00a.m. to 4:00 p.m.). As parents arrived for follow-up, the staff activated the Bili Clinic process, noti-fied the newborn health care provider of the new-born’s arrival, and initiated procedures (weight,transcutaneous bilirubin, or serum bilirubin) as re-quested. Based on the test results, the decisionwas made to provide further patient follow-up,discharge home, or admit the newborn for treat-ment. This process for at-risk infants bypassedthe emergency department and facilitated prompttreatment at the Bili Clinic.

Implications for Nursing PracticeEvaluation is ongoing based on patient commentsand efficiency of workflow for nursing staff. Infantsreceived phototherapy in a timelier manner andthus increased patient and nurse satisfaction, de-creased overall costs, and promoted better out-comes for the patient.

Operationalizing Palliative Care Processes through aPerinatal Palliative Care Program

Becky Gams, RN, MS, CNP,University of MinnesotaMedical Center, Fairview,Minneapolis, MN

Keywordscomfort carepalliativelossnewbornlife-limitingfetal



Parents who receive a life-limiting fetal diag-nosis face many unexpected decisions: con-

tinue the pregnancy or proceed with early termi-nation, comfort care or pursue neonatal intensivecare intervention, treatment options with secondopinions or withdrawal of life sustaining measures.The program offers a formalized care process forfamilies choosing to continue the pregnancy andutilize comfort care for their newborn at the time ofbirth.

Proposed ChangeThe University of Minnesota Amplatz Children’sHospital’s Perinatal Palliative Care is a family-centered, multidisciplinary program that providesa continuum of medical, emotional, psychosocial,and spiritual support through diagnosis, preg-nancy, birth, and death. Throughout this process,parents are supported in creating a plan of carefor their baby that is consistent with their goals andwishes. The program goals address the NationalQuality Forum’s Preferred Practices for PalliativeCare and support caregivers in meeting palliativecare outcomes.


Gams, B. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Implementation, Outcomes, and EvaluationHistorically, care for these families was heroicallypulled together by a few dedicated and passion-ate individuals. However, as the newly establishedFetal Diagnostic and Treatment Center’s patientvolume grew, the needs for families choosing tocontinue pregnancy and newborn comfort carewere expected to grow as well. Steps to formalizethe program, led by the advanced practice nurseleader, included a literature review, interviews withleaders from established programs, developmentof support from hospital administration and keyindividuals willing to operationalize the program,and creation of a multidisciplinary education pro-cess. The palliative care approach is enhancedby our established Pregnancy and Newborn Lossprogram. Although current numbers are small, av-eraging four per year from 2008 to 2010, eight fam-ilies were served in 2011 (year-to-date). Families

commented that “this was the happiest and sad-dest day of my life.” Data from patient satisfactionsurveys and multidisciplinary debriefings are dis-seminated to the health care team. Within this sup-portive formalized structure, a broad health careteam accommodates the individual needs and cir-cumstances of each family in the program.

Implications for Nursing PracticeThe Perinatal Palliative Care program offers thiscare model within an institution with an establishedpregnancy and newborn loss program and a re-cently established Fetal Diagnostic and TreatmentCenter. Program scope, role definitions, respon-sibilities for maternal and neonatal medical man-agement, program access, and multidisciplinaryeducation will be described. A detailed birth plantemplate, newborn comfort care orders, care con-ference documentation, and process workflow willbe displayed.

Baby Cuddlers Make a Difference

Monica C. Kraynek, MS,RNC-LRN, RN-BC, TheWestern Pennsylvania Hospital,Pittsburgh, PA

Mona Patterson, RN, BSN, TheWestern Pennsylvania Hospital,Pittsburgh, PA

Christina Westbrook, RN, BSN,MSN, MBA, The WesternPennsylvania Hospital,Pittsburgh, PA

Keywordsbaby cuddlerneonatal abstinencelength of stay



The number of newborn infants treated everyyear at the Western Pennsylvania Hospital

for neonatal abstinence syndrome (NAS) has in-creased more than 150% since 2004. Nurses con-duct the Finnegan Neonatal Abstinence ScoringTool every 2 hours to analyze the infant’s with-drawal symptoms and determine if pharmaco-logic intervention is necessary and/or effective.Up to 30% of infants may be managed withoutmedication. Interventions for treatment of theseinfants include medication and supportive care.The purpose of the program, as a unit evidence-based practice project, was to learn if the additionof baby cuddlers as caregivers could affect thelength of stay required for treatment of these in-fants.

Proposed ChangeA baby cuddler is a trained baby holder whocan fill the gaps when parents are not able to bepresent. The cuddler provides an important com-ponent of the developmental care for the hospi-talized infant. The importance of human contactand touch in the well being of all hospitalized in-fants has been well documented. Baby cuddlerson a daily basis held, rocked, and comforted theinfants suffering from drug withdrawal.

Implementation, Outcomes, and EvaluationSeventy-five infants were admitted to the depart-ment with the diagnosis of NAS in the 1-year studyperiod from May 2009 to May 2010. Length of staywas compared from the first 6 months without thebaby cuddler program to the last 6 months afterthe initiation of the program. From May 2009 to Oc-tober 2009, the average length of stay for infantswith NAS was 26.2 days without the baby cud-dler program. From November 2009 to May 2010,the average length of stay for infants with NAS was22.4 days, a decrease in length of stay of 3.8 days.After the official evidence-based project ended,from May 2010 to April 30, 2011, the pediatricunit cared for an additional 75 NAS patients. Thelength of stay average was 23.9 days, a decreasein length of stay of 2.3 days compared with the ini-tial noncuddler group. Baby cuddlers completedan orientation to their role and received educationon hand washing and Health Insurance Portabilityand Accountability Act regulations. From initiationof the project on October 1, 2009, to February28, 2011, baby cuddlers have contributed 2,855hours of cuddling to patients suffering from NAS.

Implications for Nursing PracticeNurses have implemented a low-cost interventionthat decreases length of stay and, thus, affectshospital finances and provides quality patient careto a vulnerable population.



Normal Newborn Nursery – Neonatal Intensive Care Unit:What’s in Between?

Judith Pfeiffer, BSN, RN-C,Lehigh Valley Health Network,Allentown, PA

Denise Keeler, BSN,RNC-NIC, Lehigh ValleyHealth Network, Allentown, PA

Keywordstransitional NICUtransitional newborn nurseryobservational nursery



A trend of term newborns requiring transferfrom the newborn nursery to the neonatal in-

tensive care unit (NICU) was identified in a LevelIII NICU at a Magnet hospital. This offering will de-tail the pragmatic strategies utilized to decreaseNICU admissions of high-risk transition newbornsand present specific obstetric-related diagnoses.

Proposed ChangeTo develop standards in clinical practice to pro-mote newborn stabilization specific to newbornsdelivered between 35 and 36 weeks of gestation,born to mothers with chorioamnionitis or diabeteswho received intravenous (IV) insulin during la-bor. Nurses are critical to assess, plan, act, andevaluate care for high-risk transition newborns toimprove clinical outcomes and increase efficiency.

Implementation, Outcomes, and EvaluationA collaborative team approach was taken to es-tablish clinical criteria to identify infants at risk oftransfer to the NICU. Standards were developedfor newborns delivered between 35 and 36 weeksgestation, born to mothers with chorioamnionitisor diabetes who received IV insulin during labor.These infants, high-risk transition newborns, areadmitted to the NICU for up to 6 hours of obser-vation. Glucose management, breastfeeding, andnewborn admission policies were revised to re-flect new processes. The criteria and interventionswere standardized and embedded into practice. A

multidisciplinary approach was utilized to assureall care providers involved with maternal–newborncare received education, including process flowcharts, algorithms, and reference cards. The cri-teria were communicated to the family prior to de-livery to ensure inclusion with all aspects of care.To foster family-centered care, families were madeaware of where their newborns would be admitted.Since July 2008, full-term hypoglycemic newborntransfers decreased 15% from the mother–babyunit to the NICU, the admission of high-risk transi-tion newborns to the NICU increased 27%, and thetransfer of all newborns back to the mother–babyunit is about 80%.

Implications for Nursing PracticeClinical criteria to identify newborns at risk of in-stability during extrauterine transition of life werestandardized and embedded into practice. Thesecriteria provided necessary collaborative nursingand medical management of the newborn patientcare for the newborn nursery registered nurse andthe primary care pediatrician. Clinical autonomywas maintained for the NICU nurse who providedcare to the newborn during the transitional timeframe. Standard processes and care requirementsenabled nurses in a NICU to make prudent andtimely decisions to improve neonatal outcomes.Improved quality outcomes for the newborn andimproved patient satisfaction are a direct result ofa standardized plan of care for high-risk transitionnewborns.

“Wait for Eight”: Improvement of Newborn Outcomesby the Implementation of Newborn Bath Delay

Diana V. Lipka, RNC, BA,Baycare/Saint Joseph’sWomen’s Hospital, Tampa, FL

Marcia K. Schulz, RNC, MS,Baycare/Saint Joseph’sWomen’s Hospital, Tampa, FL

Keywordsnewborn bath delayskin-to-skintransition



To improve newborn outcomes by implement-ing the evidence-based research to delay

bathing the newborn.

Proposed ChangeTo improve newborn outcomes, implementationof evidence-based research was initiated. Imple-mentation of bath delay showed that regardlessof gestational age, the incidence of newborns ex-periencing hypothermia and hypoglycemia duringthe transitional period was reduced by changingthe focus of unnecessary interventions.

Implementation, Outcomes, and EvaluationTo review the current practice and identify the pri-oritization of the nursing task over the outcomesof bathing, the newborn, newborn care guidelinesincluding revision of newborn order sets were es-tablished. Reference to evidence-based researchand data collection post-implementation of guide-lines were utilized. Multidisciplinary team actionsinvolved evidence-based practice data regardingthe effectiveness of newborn bath delay. Script-ing to parents and families were created, whichincluded the development of crib cards in orderfor clinical staff to facilitate the process change bydirect hands-on education.


Lipka, D. V. and Schulz, M. K. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

The description of the process from admission todischarge identified the value in bath delay relatedto skin-to-skin research. Global hospital staff edu-cation was initiated and staff were presented withadvice to give to parents and families during new-born care education. The value of skin-to-skin carewith transition, bonding, and breastfeeding wasemphasized. Our efforts were validated by the im-proved outcomes of practice change of newbornbath delay, which resulted in increased patient sat-isfaction.

Implications for Nursing PracticeHistorical review of newborn care delivery demon-strated that nursing has shown to place prior-ity on the completion of nursing tasks over the

outcomes related to the newborn transitional pe-riod. To improve newborn outcomes, implemen-tation of evidence-based research was initiatedto foster practice change. The research of skin-to-skin practice directly correlated the need to reviewnewborn care and practices thereof. The need toreview one such practice was the newborn bath.Recognition of the importance of an uninterruptednewborn transition resulted in positive newbornoutcomes and patient satisfaction. Implementa-tion of bath delay showed that regardless of ges-tational age, the incidence of newborns experi-encing hypothermia and hypoglycemia during thetransitional period was reduced by changing thefocus of unnecessary interventions.

Buccal Care with Colostrum in the Low Birth Weight Infant

Kimberly Pinkerton, MSN, RN,RNC-NIC, IBCLC, MissionHospital System, Asheville, NC

Jennifer Wilkinson, BSN,RNC-NIC, Mission HospitalSystem, Asheville, NC

Keywordslow birth weight babiesbreast milkNICUbuccal care



There is overwhelming evidence in the literaturethat human milk is superior to any form of nu-

trition for the neonate. It contains immunological,nutritional, and developmental properties that pre-vent infection, provide individualized nutrition, andoptimize brain growth and visual development.Recent studies have proven that the protectivefactors in colostrum are even more concentratedin the colostrum of women who deliver low birthweight infants. This population of patients in theneonatal intensive care unit (NICU) is most vulner-able to morbidities, including necrotizing enteralcolitis and nosocomial infections. Human milk de-creases the incidence and severity of nosocomialinfections and necrotizing enteral colitis. It alsohas been proven to protect against gastrointesti-nal and respiratory infections. Its perfect combi-nation of protein, carbohydrates, and plasma pro-teins improves gastric emptying, which promotesfeeding tolerance. The purpose of this project is topromote buccal application of mother’s colostrumfor low birth weight infants in the NICU.

Proposed ChangeThe nursing intervention of buccal application of amother’s colostrum potentially decreases the inci-dence of certain morbidities and decreases thelength of stay of these fragile infants. The pro-

posed change in practice is to institute a policyof buccal application of colostrum in the NICU.The infants are being followed longitudinally foroutcomes related to this care.

Implementation, Outcomes, and EvaluationA protocol for the buccal application of a mother’scolostrum as well as banked breast milk for alllow birth weight infants (weighing less than 1,500grams) was developed and implemented in Jan-uary 2011. Staff education was completed at staffmeetings via slide presentations. The completedpolicy also includes an education sheet for par-ents as a means of encouraging their participationin this bedside practice.

Implications for Nursing PracticeDue to the limited availability of colostrum, moth-ers are being encouraged to begin pumping within6 hours of delivery and pump on a prescribedschedule. We created syringe kits with detailedinstructions for the collection of a mother’s breastmilk to avoid waste. The initial review of chartssince the start of this policy revealed that accessto colostrum takes several days and adherenceto the policy is varied. Currently, longitudinal dataare being collected on the infant outcomes post-treatment. Ongoing education of staff and parentsis imperative to the successful implementation ofthis policy.



Don’t Drop That Baby!

Ellen Fleischman, MBA, RD,RN, Sharp Mary Birch Hospitalfor Women & Newborns, SanDiego, CA

Monika Lanciers, BSN, RN,Sharp Mary Birch Hospital forWomen & Newborns, SanDiego, CA

Keywordsfalls of infantshealth literacycultural barriersstaff education



The purpose of this poster is to share informa-tion regarding the incidence of falls of infants,

the education strategies employed to decreasethe risk of falls, as well as to explore future plansfor decreasing the rate of falls of infants at thematernal infant services unit at Sharp Mary BirchHospital for Women & Newborns.

Proposed ChangeInvestigations were completed to identify trendsin the falls of infants. Staff and patient educationwere developed utilizing the findings from incidentreports. Picture-based patient education was de-veloped and posted in patient rooms for easy ac-cess by patients and visitors.

Implementation, Outcomes, and EvaluationFocused staff and patient education were imple-mented in April 2010. In 2009, there were 5.83falls per 10,000 live births, and in 2010 there were

2.5 falls per 10,000 live births (8,568 live births in2010). Three falls occurred in 2010 prior to the im-plementation of staff and patient education. Fromthe implementation of education, there were nofalls for nearly a year. At the time of this abstractsubmission, there were 0.43 falls per 10,000 livebirths (4,341 live births as of June, 2011).

Implications for Nursing PracticeThe success of patient education may be at-tributed to the goal of educating the patients andvisitors as well as providing education to illiter-ate or non-English speaking patients. The patienteducation posters were translated into Spanish;however, patients at Sharp Mary Birch Hospitalfor Women & Newborns originate from a varietyof countries and speak many different languages.To optimize comprehension of patient education,consideration should be given to utilizing picturesin addition to text.

Reducing Catheter Associated Bloodstream Infectionsin the Neonatal Intensive Care Unit: Challenging Nursesto Be Champions

Jayne Solomon, MSN,ARNP-BC, St. Joseph’sWomen’s Hospital, Tampa, FL

Keywordscentral line associated blood

stream infectionsquality championcentral line bundlehand hygienerandom auditneonatal intensive care unit



Central line-associated bloodstream infections(CLABSI) are associated with increased mor-

tality and adverse outcomes in multiple systemsin the neonatal intensive care unit (NICU) patient.All of the literature in the past 2 years regardingCLABSI has shown that with the implementationof evidence-based strategies, CLABSI can be sig-nificantly reduced and in some cases completelyeliminated. In June 2009, a designated committeeat St. Joseph’s Women’s Hospital’s NICU beganreviewing central line care and the current liter-ature concerning best practices for central linemanagement.

Proposed ChangeA comprehensive program was developed, anda timeline was established to implement multipleinterventions into the unit’s guidelines for the man-agement of central lines.

Implementation, Outcomes, and EvaluationStrategies included the following: (a) hand hy-giene, (b) development and implementation ofcentral line insertion and maintenance bundles,(c) validation for a team of nurses to perform pe-ripherally inserted central catheter (PICC) inser-

tion and dressing changes, (d) competency val-idation for all staff performing central line bloodsampling, (e) standardized central line tubingchange policy, (f) daily audits of all central linesfor integrity and necessity, (g) “scrub the hub”care, (h) random audits, and (i) development ofa standardized sterilized PICC dressing changekit. CLABSI rates in the NICU decreased progres-sively from 10.17 per 1,000-catheter days just be-fore the initiative begun in June 2009 to 5.84 per1,000-catheter days by the end of the year. TheCLABSI rate for 2010 was 3.37 per 1000-catheterdays. The number of bloodstream infections de-creased from 30 in 2009 to 10 in 2010, a 67%decline.

Implications for Nursing PracticeA comprehensive program of central line manage-ment, led by a quality champion, is effective insignificantly reducing CLABSI in the NICU. Thedesignation of a quality champion who is respon-sible for the initiative is vital to the success of thisprogram. This role includes overseeing and partic-ipating in staff education, motivating and commu-nicating with the team, random audits, and gath-ering surveillance data for quality improvement.


Bagby, K. and Bowen, S. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

Kangaroo Care Increases Breastfeeding Rates

Kim Bagby, RNC, BSN, PCE,University of LouisvilleHospital, Louisville, KY

Susanna Bowen, RN, BSN,PCE, University of LouisvilleHospital, Louisville, KY

Keywordskangaroo careskin-to-skin contactbreastfeedingbarriers to kangaroo care



For eligible mother–infant dyads, does imple-mentation of Kangaroo care at birth increase

breastfeeding rates compared to retrospectivebreastfeeding rates?

Proposed ChangeKangaroo care, or skin-to-skin contact, began in1979 in Bogota, Columbia, as a way to keep in-fants warm and provide optimal nutrition followingbirth. Research has shown that Kangaroo care hasmany benefits for mothers and infants, includingincreased breast milk supply and greater breast-feeding success. The American Academy of Pedi-atrics recommends skin-to-skin contact as a strat-egy to increase breastfeeding success. In 2007,a Kangaroo care program for healthy infants andtheir mothers at the University of Louisville Hospi-tal (ULH) was implemented. However, the philos-ophy was not adopted as a standard of care until2010. Strategies were developed to hardwire theprocess and facilitate a change in practice thatsupported the use of Kangaroo care.

Implementation, Outcomes, and EvaluationCurrent literature was examined, policies wererevised, and staff expectations for participationwere established. Kangaroo care champions wereidentified and assisted other staff with completionof Kangaroo care competencies; also three staff

members received certification in Kangaroo care.Documentation was improved to facilitate accu-rate data collection. Breastfeeding and Kanga-roo care progress was shared monthly with staff.Breastfeeding initiation rates increased from 51%in July 2010, to 74% in July 2011. During this timethe percentage of eligible infants who were placedin Kangaroo care at birth increased from 60%to 73%. The percentage of mothers and infantsdocumented as participating in Kangaroo care inthe mother–baby unit also increased from 35% to51%. Ninety percent of the labor and delivery staffand mother–baby staff completed the Kangaroocare competency assessment in the 12 monthsfollowing July 2010.

Implications for Nursing PracticeImplementation of the Kangaroo care initiativeimproved breastfeeding rates in the populationserved by the ULH. It is essential that all levels ofleadership support and monitor standard of carepractice at the bedside. In addition, accurate datacollection and a comprehensive educational pro-gram are vital to support the initiative. Staff ac-countability is crucial to any successful changein practice. Our journey continues with further ed-ucation and improved practices. This quality ini-tiative is being shared with 57 birthing hospitalsthroughout Kentucky.

The Perfect Pouch: A March of Dimes Interventionto Enhance Onset and Frequency of Kangaroo Care

Liza G. Cooper, LMSW, Marchof Dimes Foundation, WhitePlains, NY

KeywordsKangaroo Careskin-to-skinstaff resistanceparent awareness



The national evaluation results of the Marchof Dimes NICU Family Support program re-

vealed that neonatal intensive care unit (NICU)parents felt that the most comforting activity thatcould be offered in the NICU would be to holdtheir infants. Staff respondents also reported thebenefits of Kangaroo care include reduced stress,enhanced comfort, and increased parent–infantbonding, but only 8% of staff reported routinelyoffering Kangaroo care to families. The March ofDimes developed the Close to Me intervention toincrease the early onset and frequency of Kanga-roo care in NICUs.

Proposed ChangeThe Close to Me intervention includes parent ed-ucation and awareness materials, staff educationmaterials, and items of comfort and encourage-ment for families. This presentation will share thecomponents of the Close to Me intervention aswell as what was shown to be most effective in theevaluation.

Implementation, Outcomes, and EvaluationClose to Me was unveiled in March of DimesNICU Family Support R© program sites nationwide.In 2011, a national evaluation of Close to Mewas conducted in four NICU sites using an out-side consultant who conducted staff focus groupsand surveys preintervention and postintervention,



parent surveys, and a special parent journalingtechnique. Results will be shared regarding themost effective components of Close to Me andthe changes in parent and staff perceptions frompreintervention to postintervention. We workedclosely with a large team of NICU staff on adapt-ing our materials for the full-term NICU infants andthe full-term, well-baby audiences of profession-als and parents. Key findings from this work alsowill be discussed.

Implications for Nursing PracticeKangaroo care is a proven benefit to newbornsand parents. Staff resistance to its implementationcan be overcome with awareness, education, and

hands-on instruction. Parents can learn to ask forand advocate for this activity if they know aboutit and its benefits early in their baby’s hospitaliza-tion. Researching Kangaroo care by having par-ents maintain a journal is appealing to parents whohave the opportunity to heal and process as theyparticipate in the study. Kangaroo care can be vitalto many if not all babies in the NICU, including full-term babies and those in the NICU for a short stay.The physiological, medical, and emotional bene-fits of Kangaroo care are worth the additional timerequired in educating staff and providing comfort-ing space and opportunities for parents to Kanga-roo care their infants.

A New Look At Infection Control in the Neonatal IntensiveCare Unit

Michele L. Carson, MSN-CNL,RNC-NIC, UCSD MedicalCenter, Del Mar, CA

KeywordsNICUCLABSIquality initiative



To reduce infection rates in the neonatal inten-sive care unit (NICU) by 30%.

Proposed ChangeTo educate and implement policy to reduce theNICU infection rates.

Implementation, Outcomes, and EvaluationTo change the way we look at preventing infec-tions in the NICU, the aim of this project was torecreate the policy and procedure on infectioncontrol for the NICU. This project was started inJuly 2008 after the unit joined the California Chil-dren’s Quality Initiative in January 2008. The initialgoal for 2008 was to reduce infection rates in theNICU by at least 30%. This project was completedas follows: the California Children’s Quality Initia-tive guidelines were collected and incorporatedinto the current infection control policy for the unit;each policy concerning infection control was re-viewed; the last 5 years of peer-reviewed litera-ture on infection control pertaining to neonatal in-tensive care was reviewed, and pertinent informa-tion was added to the policy and procedure; andeach multidisciplinary group in the NICU was metwith (for example the peripherally inserted centralcatheter team). These teams compiled input, andthe information was added as appropriate to thepolicy. Finally, the policy was reviewed and ap-

proved by the medical director and delivered tothe core group for the unit.

Once the policy was finished, the staff memberswere educated through the creation of a six-panelposter session on the policy. Each staff memberwas required to walk through the poster sessionand answer a set of competency questions thatpertained to the poster session. Also, a parentagreement was created that centered on infec-tion control, which holds parents to the same stan-dards as the nurses and doctors. During this time,specific audit tools were used to assess staff ad-herence to the components of the policy. Overall,the infection rate was reduced by 58% and auditdata showed adherence to be at 96% and greater.These data were presented to the 2009 Califor-nia Perinatal Quality Control Collaborative annualmeeting in Sacramento and at the hospital-wideinfection control committee. The policy was ap-proved by the hospital-wide infection control com-mittee and is under review for adoption on otherhospital units.

Implications for Nursing PracticeAt this time our efforts are focused on sustainingthe gains. We are accomplishing this by review-ing current evidence-based practice yearly andchanging practice accordingly, continuing to com-plete audits on practice, and providing continuingeducation to new and current staff.


Woodson, L. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

What Do You Mean You Dropped Your Baby? Changingand Hardwiring Nursing Practice to Eliminate Infant Falls

Linda Woodson, RN, BSN,Baylor All Saints MedicalCenter- Andrews Women’sHospital, Fort Worth, TX

Keywordseducationnewborn safety sheetsnuggle timehourly rounding



I n the first 2 years that Andrews Women’s Hospi-tal was open, we experienced eight infant falls.

The proposed changes were to hardwire hourlyrounding on all shifts, to educate families on safesleeping arrangement, and to promote maternalrest.

Proposed ChangeOur goal was to eliminate infant falls at AndrewsWomen’s Hospital.

Implementation, Outcomes, and EvaluationWe implemented the project by first using a tallysheet to identify common trends that occurred inthe falls of newborns. Then, we educated both thenewborn nursery and the postpartum staff on theneed to hardwire the hourly rounding on all shifts.Next, we developed a newborn safety sheet thatdescribed the elements of safe sleeping and re-

quired that both the mother and the significantother sign the sheet because three infants hadbeen dropped by fathers. In addition, we empha-sized with the newborn nursery staff and postpar-tum staff how important it was to make sure that themother has the call bell within reach, even whenshe is placed in a chair. We began an extensivecampaign to make sure that the mothers under-stood the adverse effects of pain medication. Inaddition, the postpartum registered nurse (RN)would alert the RN nurse when the mother hadtaken pain medication. Finally, we initiated “snug-gle time” every day from 2:00 to 4:00 to promotematernal rest without interruptions. The outcomehas been very positive, and it has been 1 yearsince the last fall of a newborn occurred.

Implications for Nursing PracticeEducation of families and hourly rounding are ab-solutely necessary for keeping our infants safe.

Supporting Breastfeeding in the Hospital: A Better Start

Tessa Brown, BSN, RN, CLC,Bristol Regional MedicalCenter, Bristol, TN

Maggie Redmon, RN, C-EFM,Bristol Regional MedicalCenter, Bristol, TN

Keywordsskin to skinearly pumpingexclusive breast milk feedingeasy access for rental supplies



Breast milk feeding is the best option for in-fants and exclusive breast milk feeding is

supported by the American Academy of Pedi-atrics for the first 6 months of life. In addition, theJoint Commission recently introduced PC-05, rec-ommending exclusive breast milk feeding duringan infant’s entire hospital stay. Our goal was to in-crease the rates of breast milk feeding during theduration of the hospital stay and the rates of infantswho were exclusively fed breast milk at dischargeto promote what is best for infants and comply withthe the Joint Commission’s recommendation.

Proposed ChangeOur plan was to increase the support and durationof exclusive breast milk feeding by placing infantsskin-to-skin during the immediate post delivery pe-riod. Second, we planned to begin encouragingearly pumping for mothers of infants that were notbreastfeeding well or were unable to nurse. Wethen planned to make breast pumps and suppliesmore readily available for our patients. Our staffwould then be educated on the changes.

Implementation, Outcomes, and EvaluationOur unit began implementing changes to supportthe breastfeeding relationship in the above men-tioned areas. We began placing all breastfeed-

ing infants skin-to-skin within the first hour and al-lowed them to self-attach to the breast for the firstfeeding, which has been shown to increase thesuccess of breastfeeding by approximately 80%.Second, we began to encourage early pumpingfor infants that were not feeding well at the breastor were unable to be at the breast because of med-ical conditions. We then looked at how we couldsupport the use of breast pumps for our patientpopulation. This was accomplished by partneringwith a pharmacy in the Bristol Regional MedicalCenter to provide easy rental of breast pumpsas well as breastfeeding supplies at competitiveprices. Finally, we educated our nursing staff onthe importance of supporting breastfeeding, al-lowing them to become breastfeeding advocatesfor our patients.

Implications for Nursing PracticeBy implementing these changes, we were able toprovide the early intervention and support neces-sary for our patient population. Patients are ex-cited about the skin-to-skin process and our earlysupport and intervention. Our partnership with thepharmacy has allowed our patients easy accessto breast pump rentals and supplies. Combiningthese interventions has a great potential to in-crease the rates of exclusive breast milk feedingduring the hospital stay and beyond.



Babies, Bonding and Breastfeeding in the Post-AnesthesiaCare Unit: Innovative Family Centered Care in a CommunityHospital

Lauren Griffin-Walls, BSN,RNC-OB, Milford MemorialHospital-Bayhealth, Milford,DE

Jaclyn Lewis, RN-CPN,Milford MemorialHospital-Bayhealth, Milford,DE

KeywordsbabiesbondingbreastfeedingPACU



I n many cultures, newborns are placed nakedon their mothers’ chests immediately after birth,

which is viewed by many as necessary for the in-fants’ survival. In most community hospitals, moth-ers and infants are separated quickly after ce-sarean birth and not reunited until hours later.In collaboration with our post-anesthesia recov-ery team, our obstetric nurses created a seamlessprocess to keep the mother and infant togetherthroughout the challenging postoperative period.

Proposed ChangeIn an effort to provide immediate skin-to-skin con-tact and allow for early breastfeeding for mothersand their healthy infants after operative deliveries,the roles and responsibilities of the labor and deliv-ery nurses were changed. These changes enablethe nurse to be off of the labor and delivery floorand provide both intraoperative and postoperativeone-on-one care for the newborn and mother as aunit.

Implementation, Outcomes, and EvaluationA multidisciplinary team was formed that con-sisted of labor and delivery nurses, postanesthe-sia recovery team members, lactation consultants,

and the director of women’s services. This teamwas formed to change the policies and proce-dures to allow infants to remain with their mothersafter a cesarean birth and the immediate post-partum surgical recovery period. A process wasdeveloped to assist with the implementation of thenew procedures and to educate and direct nursingteams involved with cesarean births. Evidence-based best practice was used to guide staff ed-ucation. The education incorporated the impor-tance of skin-to-skin contact between the motherand baby and early breastfeeding after an opera-tive delivery. Evaluation revealed that keeping themother and baby together after cesarean birth in-creased patient satisfaction, enhanced quality ofcare, allowed skin-to-skin contact, promoted earlybreastfeeding, and supported thermal regulationof the newborn.

Implications for Nursing PracticeImplementing “Babies, Bonding, and Breastfeed-ing in the Post-anesthesia Care Unit” enhancesoverall postpartum operative care, fosters team-work between nursing units, and supports theAssociation of Women’s Health, Obstetric andNeonatal Nurses’ commitment to positive perinataloutcomes.

Decline of the Gold Standard! Umbilical Cord TissueProvides Timely and Accurate Results to Enhance QualityOutcomes for the Neonate

Tanyelle Bellamy, RNC, MSN,FNP-BC, Mountain StatesHealth Alliance, Johnson City,TN

Keywordsdrug testingsubstance abuseumbilical cord testingneonatal abstinence scoring



Recent literature reviews stated that approxi-mately 5% to 10% of women self-report the

use of illicit drugs during pregnancy; however, uni-versal testing in high-risk populations indicateshigher rates of illicit drug use. Facilities should es-tablish their own testing protocols and unbiasedguidelines to identify when testing should occurbecause the literature does not indicate consen-sus on universal screening. A positive maternaltest result determines the initiation of the protocolto test newborns.

Proposed ChangeMeconium drug screening is considered the goldstandard for drug testing in the neonate, but be-

cause of false positive test results and the lengthof time to obtain confirmatory results it was iden-tified that a practice change was necessary. Be-cause of the sensitive nature of this test, accu-racy in patient test results is crucial. Increasein false positive test results lead to question-ing the truthfulness of the test. The goal wasto identify a process that provided ease of ob-taining specimen sampling and accurate patienttest results. The proposed change was to imple-ment umbilical cord tissue screening. The ad-vantages of this process included samples be-ing sent immediately after birth, receiving onlyconfirmatory results, and a chain of custody. Be-cause of the sensitive nature of drug testing andpossible legal ramifications, a chain of custody


Bellamy, T. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

was seen as a necessary piece of our processimprovement.

Implementation, Outcomes, and EvaluationThe plan was discussed and approved by theneonatologists and pediatricians. Nursing leader-ship met with pathology and lab directors to dis-cuss switching the testing location from a local lab-oratory to sending the tests to an outside referencelab. Initial implementation began at a regional ter-tiary care facility and a smaller community hospitalwhere the largest volumes of maternal substanceabuse were experienced. The outcomes focused

on increasing result turnaround times, potentiallydecreasing the newborn’s length of stay, and de-creasing rates of false positive test results.

Implications for Nursing PracticeThe implications for the nursing practice in-cluded the need for a standardized order setfor newborns experiencing neonatal abstinencesymptoms, which was developed in collaborationbetween the departments of nursing and neonatol-ogy. All nursing staff received in-service on neona-tal abstinence scoring to help staff provide moreconsistent and accurate scores.

At Home with Your Baby

Deborah Raines, PhD, EdS,RN, ANEF, Walden University,Boca Raton, FL

KeywordsNICU dischargesimulationcaregiver competence



This community-based program is designedto enhance parents’ competence and confi-

dence as caregivers after their infants’ dischargefrom the neonatal intensive care unit (NICU).

Proposed ChangeBy enhancing parent confidence and compe-tence, this program will improve infant, parent, andoverall family well being. The program also has thepotential to decrease the use of health care re-sources, such as 911 calls, emergency resourcesvisits, and hospital readmission.

Implementation, Outcomes, and EvaluationThe program is conducted in the departmentfor caregiver education and uses a preemiehigh-fidelity simulator. The specific activities are

adapted to the anticipated discharge needsof the infant. The program accepts referralsfrom all the NICUs in the county and fromthe Health Department. The program began ac-cepting referrals in January 2011. To date, theevaluation of parents and staff has been over-whelmingly positive and the funding has beenextended for a second year. Data are being col-lected on the specific outcomes of parent confi-dence and competence as caregivers as well ason unscheduled use of health care resources oninfants.

Implications for Nursing PracticeThe use of high-fidelity simulators may have a sig-nificant role in the process of discharge teachingin the NICU.

Making Kangaroo Care the Norm: Implementation of a NewModel of Care

Lynn Barabach, MSN, RNC,Lakewood Hospital, Lakewood,OH

Joy Sedlock, MSN, CNM,IBCLC, Lakewood Hospital,Lakewood, OH

Kate Salmon, RNC, MSN,IBCLC, Lakewood Hospital,Lakewood, OH

Keywordskangaroo careinfantchildbirthbreastfeeding



I n 2009, the Lakewood Hospital Birthing Cen-ter embarked on the journey to obtain Baby-

Friendly, USA designation. It was identified thata key component for a successful journey wasthe implementation of Kangaroo care, or skin-to-skin care, in the immediate postpartum period. Inthe fall of 2009, the Birthing Center began trainingthe nurses on Kangaroo care and implementationsoon followed.

Proposed ChangeOur goal was that all appropriate infants wouldbe placed in Kangaroo care shortly after birth andwould remain with their mother or the mother’s sup-port person for 60 to 90 minutes. The time in Kan-garoo care with the mother would facilitate tran-sition to extrauterine life and allow the infant toself-latch at the breast.

Implementation, Outcomes, and EvaluationNursing leadership worked with a nationally rec-ognized expert on Kangaroo care to provideeducation to the nurses. A 4-hour program onKangaroo care was developed and included dis-cussion of the benefits, infant placement, and on-going care of the infant, including assessment.Placing the infant in Kangaroo care was demon-strated to validate understanding. The electronichealth record was modified to include documen-tation of time in and out of Kangaroo care andwith whom the infant was in Kangaroo care. Pa-tient education included handouts on Kangaroocare for distribution during prenatal appointments,prepared childbirth classes, and breastfeedingclasses. Kangaroo care also is discussed dur-ing tours of the Birthing Center. Pediatric, mid-wifery, obstetric, and anesthesia providers wereeducated about Kangaroo care and the Birthing



Center’s change in the model of care immediatelyfollowing birth. As barriers were identified, nursingleadership worked on the issues to minimize inter-ruptions of Kangaroo care. The percentage of ap-propriate infants in Kangaroo care following birthis reviewed monthly. Between 90% and 98% ofappropriate infants are placed in Kangaroo care.Infants also are placed in Kangaroo care shortlyafter a cesarean birth while the mother remains inthe operating room. Anecdotally, lactation consul-tants report a decrease in the incidence of delayedlatch and breastfeeding problems. Families have

reported increased satisfaction with their birthingexperiences.

Implications for Nursing PracticeKangaroo care assists the infant with transition andfacilitates initial breastfeeding, it is beneficial to theinfant, mother, and family, and it is utilized through-out the hospital stay and families are encouragedto continue Kangaroo care at home, especially inconjunction with breastfeeding. The use of Kanga-roo care is truly a nursing intervention. This nurs-ing intervention quickly became a model of carefor the Birthing Center.

Discharge Planning in the Neonatal Intensive Care Unit

Kathy J. Loughren, MSN,NNP-BC, Memorial HospitalMiramar, Miramar, FL

Keywordsneonatal intensive care unit

(NICU)



To improve parents’ ability to care for their in-fants at discharge.

Proposed ChangeTo implement the following improvements in theneonatal intensive care unit (NICU):

� Cultural: More parental involvement. Parentswould hold infants every day. Parents get apicture on admission. Long-term infants geta journal with weekly pictures.

� Teaching: A parent admission and dischargetool was created. Videos will be added to ourtelevision system for parental viewing. Reg-istered nurses will be held accountable fordaily teaching and documentation.

� Parental Accountability: Parents will be ac-tively involved in teaching and take responsi-bility for learning.

� Discharge map created: Outline dischargeteaching with daily accountability for up-dates, holding, and teaching.

Implementation, Outcomes, and EvaluationThe clinical manager recruited two staff nurses.The classes were mandatory for NICU nurses and

included the following: an emotional approach, aliterature review, and a discussion of unit expec-tations. Issues with discharge planning, parentsbeing unprepared to take their infants home, andthe associated risks were reviewed, along withthe American Academy of Pediatrics’ guidelinesfor discharge planning, including rooming in. Ourevaluations have been overwhelmingly positive.Our parent surveys improved from the 30th per-centile for discharge planning to the 99th per-centile. Parents state that they feel at home withinthe NICU and are prepared to care for their infants.We offer all parents rooming in.

Implications for Nursing PracticeDischarge planning should begin on admission.It is not only a teaching process but should in-volve the parents in every aspect of their infants’care. We must change our culture of isolation toone of inclusion. The more involved the family is,the more prepared they are to care for their in-fant at home. Nurses must be held accountablefor discharge teaching on a daily basis. Parentsshould be actively involved and accountable forknowledge acquisition. Discharge mapping is anexcellent tool to ensure that parents have coveredall discharge information.

Nurses’ Commitment to Best Practice Infant Care andFamily Bonding Founded on Evidence-Based Research:A Journey of Infant Bathing

Rebecca Heimann, RN,Providence Alaska MedicalCenter, Anchorage, AK

Melissa Heath, RN, ProvidenceAlaska Medical Center,Anchorage, AK


The Professional Practice Committee hypothe-sized that we could improve postpartum well-

born baby care by switching from sponge bathingto immersion bathing. A research review revealedevidence supporting the theory that immersion

bathing improved temperature stability, bonding,breastfeeding, and parental education. The cur-rent practice in the Providence Alaska MedicalCenter Maternity Center is to perform spongebathing under a radiant warmer on newbornswithin 2 hours of birth in the absence of birth stress


Heimann, R. and Heath, M. I N N O V A T I V E P R O G R A M SProceedings of the 2012 AWHONN Convention

or trauma. Parental involvement is minimal be-cause of decreased mobility from anesthesia, ex-haustion, and environmental or social distractionsKeywords

bathingeducationthermoregulationinfant stabilitynewborn care


during the immediate postpartum period. Nursesalso reported that breastfeeding and skin-to-skinbonding time often was interrupted to completebaths in the allotted 2-hour recovery time.

Proposed ChangeThe Professional Practice Committee proposeda policy and procedural change to immersionbathing founded on evidence-based research,which incorporated these key principles:

� Delay infant baths 2 to 4 hours to estab-lish thermoregulation and decrease nega-tive side effects of hypothermia, includingincreased oxygen consumption, respiratorydistress, and hypoglycemia.

� Stable temperature defined as 97.7◦F to99.5◦F for 2 to 4 hours.

� Tub bathing appears to be more effec-tive than sponge bathing at maintainingbody temperature and preventing tempera-ture loss. Also, studies showed there is no dif-ference in umbilical cord infection and heal-ing rates and infants appeared more relaxedand less agitated during tub baths.

� Infants at risk of transmission of hepatitis Band human immunodeficiency virus from ma-ternal sources will be bathed within 2 hoursof birth.

Implementation, Outcomes, and EvaluationThe Professional Practice Council presented theirresearch and findings to the Nursery Committeeand received permission to proceed with a prac-tice change. Currently, the Professional PracticeCouncil is developing a training video, policy, andcare competency. These tools will be presentedto the staff at regularly scheduled staff meetings.Hands-on training of nurses and techs will beconducted to assure comfort and competency inpractice. The goals for this project are consis-tent immersion bathing per guidelines, increasedinfant relaxation, increased parental involvementand education covering proper positioning, tem-perature regulation, and signs and symptoms ofinfant distress.

Implications for Nursing PracticeIncreased parental involvement in newborn careresults in greater uninterrupted bonding time, im-proved breastfeeding, extended skin-to-skin con-tact in the postpartum period, as well as improvedneonatal outcomes from decreased cold stressand calmer stabilization.

Outpatient Newborn Hearing Screening Program

Nicole Giangregorio, BS, CLE,LCCE, Sharp Mary BirchHospital for Women &Newborns, San Diego, CA

Keywordsoutpatientcommunityhospital growth



The Newborn Hearing Screening Program is aCalifornia state mandated program requiring

all infants to have a hearing screening prior to dis-charge. Sharp Mary Birch Hospital for Women &Newborns additionally offers an outpatient hear-ing program for our well-baby population leadingto increased patient satisfaction and delayed ap-pointment times.

Proposed ChangeTo increase the number of patients receiving out-patient hearing rescreenings, decrease the timebetween the initial hearing screening and thefollow-up hearing screening, and increase rev-enue.

Implementation, Outcomes, and EvaluationThe outpatient program allows our hospital toschedule the follow-up appointment for all well-babies prior to discharge, ensure a reminder callis made, complete all necessary paperwork, andguarantee an appointment well within the staterecommended 4-week timeframe. Compared toour region, our outpatient no-show rate is consid-erably lower. The region reported a no-show rate of12.3% for July 2011 and Sharp Mary Birch Hospi-tal for Women & Newborns reported a 0% no-show

rate (the overall program no show rate is currentlybeing calculated by the Regional Hearing Coor-dinating Center). Each outpatient appointment re-ceives a reminder phone call 48 hours prior to theirappointment. On the day of their appointment, thefamily is received and escorted to the outpatientclinic by a hearing screening technician. New par-ents are relieved to come back to the hospitalwhere they gave birth versus going to a differentclinic and navigating a new health system. As a re-sult, our patients are more satisfied. The outpatientrevenues previously went to other hospitals withinthe community, and Sharp Mary Birch Hospital forWomen & Newborns now receives revenues fromthe insurance companies and the state for Medi-Cal and/or uninsured patients. Since the outpa-tient program began in October 2008, we haveseen 382 outpatients with a steady increase eachfiscal year. The outpatient program is open to thecommunity at-large allowing for quicker access toa follow-up hearing screening.

Implications for Nursing PracticeIt is important for families to have their outpatientfollow-up appointments within the same healthsystem for convenience, increased patient satis-faction, and increased revenue.



An Innovative Program to Support and PromoteBreastfeeding: What Have You Done for Me Lately?

Lynn E. Bayne, PhD, NNP-BC,RN, Christiana Care HealthSystem, Newark, DE

Elizabeth Chance, EdD, RN,Christiana Care Health System,Newark, DE

Lydia Henry, MSN, RNC-OB,CCE, IBCLC, Christiana CareHealth System, Newark, DE

Keywordscomprehensive breastfeeding

programChristiana Care Health System

(CCHS)



Despite evidence for breastfeeding benefits,hospitals fall short in breastfeeding rates and

duration. Recent Centers for Disease Control andPrevention data suggest less than 4% of U.S. hos-pitals offer the full support necessary to meetenduring, committed breastfeeding, and nearly75% do not provide maternal support after dis-charge. This challenges an institutional ability tomeet the Healthy People 2020 goals to have 81.9%of mothers initiate breastfeeding, 60.6% breast-feed at 6 months, and 34.1% breastfeed at 1 year.The Surgeon General’s Call to Action to SupportBreastfeeding underscores this critical need, not-ing low priorities for breastfeeding, and use ofnonevidence-based practices as barriers to en-during breastfeeding.

Proposed ChangeTo create a comprehensive breastfeeding pro-gram to meet the challenges stated above

Implementation, Outcomes, and EvaluationChristiana Care Health System has built an endur-ing lactation program available across the con-tinuum of perinatal care aimed to meet theseaction calls. Support is offered to mothers andother perinatal clinicians by experienced lactationconsultants to overcome breastfeeding obstacles.This program promotes the development of knowl-edgeable mothers and health care providers. Ourfacility maintains a free, breastfeeding hotline thatis staffed by lactation consultants. Mothers mayinitiate a call at any time during their breastfeed-ing experience when they encounter questionsor concerns. As part of this program, logs doc-ument telephone conversations. To ensure that

mothers are being offered relevant information,logs were subjected to qualitative analysis, whichdetermined the nature of maternal concerns. Tenthemes emerged and specific, predictable breast-feeding topics developed at key points during thefirst year of life.

Data from 1,025 mothers who breastfed and calledduring 2009 were examined. Findings were thencompared to the nurses’ perceived breastfeed-ing barriers by care area, as defined in a sep-arate performance improvement project. Resultsof both projects clearly indicated the need toinitiate breastfeeding education activities duringprenatal classes, maintain momentum during theinpatient phase, and provide anticipatory postdis-charge guidance so that a successful support pro-gram would be in place to meet the aforemen-tioned goals.

Implications for Nursing PracticeA team approach focused on breastfeeding tosupport maternal-child nurses and mothers is oneway to improve hospital practices and meet goals.Inpatient nurses should address predictable ar-eas of concern with new mothers, particularlyconcerning milk supply, baby behaviors, andpumping. Outpatient clinicians can offer antici-patory guidance based on consistent patternsof data across the postpartum period, such asdrug and diet interaction with milk, stooling pat-terns, and weaning among other issues. Infor-mation and available resources that are appro-priately timed and offered when the mother isready to learn improve the chances that the motherwill be able to process and retain the sharedinformation.


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Don't Drop That Baby!