January 30, 2012

Newborn Procedures

There are so many things to consider and learn about when preparing for your upcoming birth. Newborn procedures may not be high on the list. If that is the case for you, here is a brief run down of what you may expect after your little bundle of joy has made his or her debut into the world!

Cord Clamping

When to cut the cord has come under great debate. Some care providers do it immediately after the baby is born with concern that the extra umbilical cord blood could lead to jaundice. Ohers allow the pulsing to stop on it’s own believing the additional blood, which is rich in iron will greatly benefit the newborn. So, which is best for you and what are the benefits to either side? The British Medical Journal recently published the largest study to date on the effects of delayed versus early cord clamping. This study concluded that waiting just 3 minutes after birth before clamping and cutting the cord has enormous benefits for the newborn. Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants even in regions with a relatively low prevalence of iron deficiency anaemia.

Antibiotic Eye Ointment

In the US, the application of antibiotic eye ointment on newborns is mandated by law in certain states.
The purpose of this routine treatment is to prevent eye infection from certain bacteria, mainly gonorrhea or chlamydia, that may be present in the birth canal. The current medication that is being used is called, erythromycin. This has replaced silver nitrate which was known to irritate some newborn’s eyes. If your state does require this eye treatment, you may want to inquire about which medication is routinely given.

Vitamin K Shot
This is given to babies at birth in the rare instance, 1 in 10,000 babies, that they are vitamin K deficient which would prevent the blood from clotting effectively. Again, some state have made this a mandated law. An alternative option for those who wish to avoid a shot, there is an oral dosage of vitamin k. If are interested in this option,you will need to consult with your care provider about how to go about securing a liquid vitamin k.

The reason some people object to the injection is because injected vitamin K ran into a problem when researchers in 1990 noted an increased incidence of childhood cancer in children given vitamin K injections at birth. Specifically, they found that injected vitamin K doubled the incidence of leukemia in children less than ten years of age. A subsequent study in 1992 revealed the same association between injected vitamin K and cancer, but no such association with oral vitamin K. These researchers recommended exclusive use of oral vitamin K.

This is usually done after the mother has had some time to bond with her new baby. It is also a big picture moment for the new family! Most of the time it is does right in the delivery room. The baby is placed on a scale and the weight is then recorded. I have heard of some hospitals taking the baby to the nursery for weight and height check. If you do not want to be separated from your baby, you can ask to have the scale brought to your room.

The Apgar, named after Virginia Apgar, is a culminated score of 5 categories, Appearance, Pulse, Grimace, Activity, and Respiration. This is done at the one minute mark and then again at the 5 minute. Each category is rated 0, 1 or 2. Zero being an absence of response in the 5 categories, 1 being slightly below what is expected and 2 being completely “normal”. The purpose of this quick test is to establish if the baby is adapting well to it’s new environment or if medical attention is needed. Since this test is done primarily by observation, it can be exectued with the baby on the mother’s body, so immediate skin to skin contact should not be disturbed by this procedure.

Hepatitis B Vaccination

Screening for Hepatitis B during pregnancy is mandated by law in many states, including NYS. However, even with this being a law, the use of this vaccination on newborns is still under great debate. Some people say that it is ridiculous to subject a newborn to another shot and a vaccination for a disease that primarily effects those that have exchanged bodily fluids with an infected person or those that had undergone a blood transfusion. Those that support this vaccination, including the CDC (Center for Disease Control) and WHO (World Health Organization). According to the CDC, approximately 33,000 children (10 years of age and younger) of mothers who are not infected with hepatitis B virus were infected each year before routine recommendation of childhood hepatitis B vaccination. While there is strong recommendation to give your newborn this vaccination, at this time Hep B vaccination is NOT mandated by law for your newborn. So the choice is yours if you would like your child to receive this vaccination.

There is also speculation of negative side effects from this vaccine. The Cochrane Summaries, a highly respected independent high quality research group concluded, Hepatitis B vaccination and hepatitis B immunoglobulin are considered as preventive measures for newborn infants of HBsAg positive mothers. When all the identified trials were combined, hepatitis B vaccine alone, hepatitis B immunoglobulin alone, and hepatitis B vaccine plus hepatitis B immunoglobulin reduced perinatal transmission of hepatitis B compared with placebo or no intervention. Hepatitis B vaccine plus hepatitis B immunoglobulin were superior to hepatitis B vaccination alone. Adverse events were rare and mostly non-serious.

Phenylketonuria (PKU) Test

Phenylketonuria is a rare metabolic disorder that if left untreated can cause mental retardation. The PKU test, developed in the 1960’s, was the nation’s first newborn screen test and is required in all 50 states. The test is done by pricking the heel of the newborn and gathering several drops of blood. The blood is then test for PKU along with several other metabolic disorders. Should the results come back positive for PKU, the baby will need to have a special formula. Many children with PKU who start treatment soon after birth and keep their Phe levels within the suggested range usually have normal growth and intelligence.

The first bath of your newborn baby does not need to be immediate. In fact, the vernix, a white cheesy substance that protects your baby’s sensitive skin from being encased in fluid for 40 weeks, can continue to serve as a protective moisturizer when massaged into the skin. If given the choice, it is best to delay the first bath at least an hour, as this will help your baby regulate his or her temperature.

Foot Prints
This procedure is pretty quick and usually done in conjunction with weighing the baby. The purpose of the newborn foot printing is for identification. Usually the nurse will do two set, one for the hospital ID records and medical records and one as a keepsake for the new parents.

Hearing test
The hearing test measures how the baby responds to sound. This simple, noninvasive, test is done before the baby is discharged from the hospital. It is recommended since significant hearing loss is the most common disorder at birth. Approximately 1%-2% of newborns are affected.

How long can you request to wait before the newborn procedures start?
This may vary from hospital to hospital, but you should be allowed at least one hour of undisturbed skin to skin bonding time assuming all is well medically with your newborn. (For more information about the importance of immediate skin to skin contact, please read Study Finds Benefit in Skin To Skin Contact)

The challenge with this is that once your baby is born, there is a lot paper work for the nurses to complete to “close your case” and allow you to move to the Maternity Unit. I am in no way diminishing the issue of understaffed, over crowded labor and delivery floors. However, having a baby is a huge event in one’s life, and if the mother desires this time to bond and establish initial breastfeeding, it should be honored. Most newborn procedures can be done in the presence of the parents, and even with the baby on the mother’s chest. Although, some hospitals do still take the baby out of the room for these procedures. If your hospitals works in that manner and you wish for some undisturbed time, discus this with your care provider ahead of time to see what you can negotiate.

What if you want to refuse any of these routine or mandated procedures?

Certain routine procedures like the vitamin K shot can be altered (as mentioned above, an oral dose is available), bathing, weighing and measuring can be put off, and even the Hep B is not mandated and parents can opt-out. If you choose to not have your child receive procedures that are mandated by law, be prepared to fight for your baby’s rights. New York is probably the most difficult state in the US in which to exercise your right to determine what goes into your body and your children’s bodies. Some people do claim religious exemptions to get by the red tape. New York is notorious for calling Child Protective Services in these instances!

After reviewing all these newborn procedures and deciding what is right for you and your family, have a discussion with your care provider to see what is possible. You should also be clear about your plan when you arrive a hospital and talk to the nursing staff about your wishes for these procedures. As a doula, I like to gently remind the staff of my client’s wishes as we approach the pushing stage so that these things are fresh in their mind. As in all aspects of birth, you don’t want to be caught unprepared.

1. CDC – Conjunctivitis: Newborns
2. http://www.cdc.gov/vaccines/vac-gen/whatifstop.htm#hepb
3. Hep B Fact sheet
4. Cochrane Summary for Hep B
5. PKU Fact Sheet
6. “>New York State Exception
7. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial



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