What should you expect at the hospital? What is going to happen to your baby? What do you need to know? Read on and find out!
During your initial registration process, they will ask you who the baby’s doctor is. If the pediatrician you have chosen is on staff at the hospital, he/she will be notified after the baby is born. If your doctor is not on staff at the hospital, there will be a pediatrician on staff who will see the baby. You will also usually be asked during the registration process to sign the consent form for the hepatitis B vaccine (see below).
The Delivery Room
Hopefully, as soon as your baby is born, you will get to see and perhaps hold her for a moment before they whisk her away to be dried off and examined by a nurse. Babies usually need their noses and mouths suctioned out. Sometimes they require some stimulation to get them to take deep breaths and cry. All this is quite normal.
Depending on the hospital policies, you will probably have the chance to hold your baby again after the initial nurse’s assessment. This is an excellent time to breast feed if you have chosen to nurse your baby. Babies are usually quite alert right after delivery and often nurse easily. Nursing is also good for helping your uterus to contract and to stop bleeding.
What they do to your baby
At some point they will take the baby away for a bath and a more thorough assessment by the nursing staff. They will do several things to your baby, as discussed below.
Group-B strep prevention
This is actually done to the mother prior to delivery. Group-B streptococcus is a common bacteria that many women are colonized with. It does not usually cause disease in women; however, babies become colonized with bacteria from mom’s vagina and perineal area at delivery, and group-B strep can cause severe or fatal infections in newborns. There is no treatment to eradicate the disease from the mother; however, treating the mother with intravenous antibiotics during delivery has been found to significantly reduce the risk of newborn disease. Mothers are tested for the bacteria at around 36 weeks of gestation. If the mom is positive, antibiotics are started during delivery. If they are started at least 4 hours prior to delivery, the risk of infection is greatly reduced.
If the mother is positive for Group-B strep and she is not treated at least 4 hours prior to delivery, then the baby usually has blood drawn for a blood count and a blood culture. The results of the blood count are available in several hours. If this looks concerning, it may be repeated later or your baby might be started on antibiotics in case there is an infection. The blood culture will determine for sure if there is an infection, but these results take 24-48 hours. Depending on the hospital and your baby’s doctor, she may be kept in the hospital at least 48 hours to await the results of this test.
Antibiotic eye drops or ointment
All babies are treated with antibiotic drops or ointment to prevent bacterial infection (with gonorrhea). Before this treatment was started, this disease was a common cause of blindness or permanent eye damage. Erythromycin or tetracycline ointment or silver nitrate drops are used. Occasionally, this can mildly irritate the eyes for several hours. There do not appear to be any long term side effects or risks of this treatment.
Vitamin K Injection
All babies get a shot of Vitamin K because some babies can bleed abnormally without this shot. This became standard practice in 1961. All babies have a decrease in Vitamin K-dependent blood clotting factors at the second or third day of life, lasting until the baby is 7-10 days old. In some babies the deficiency is severe and can cause severe and life-threatening bleeding. Premature and breast-fed babies are at a higher risk. The injection of Vitamin K prevents the disease in full-term infants and in most premature infants. The disease would actually occur in up to 2% of infants if Vitamin K were not given. Oral Vitamin K has been attempted but has not been shown to be effective. There have been concerns raised about a connection between the Vitamin K shot and childhood leukemia and cancer; research continues to show that there is no association. Although this practice is not without controversy (even in the pediatric community), currently the benefits seem to outweigh the risks (or the risks of not getting it are higher than the risks of the injection).
Hepatitis B Vaccine
In many nurseries, the baby will also get its first hepatitis B shot. This shot is part of the normal childhood immunization schedule; everyone needs 3 of these shots. Babies are at risk for getting hepatitis B only if the mother has it or if they get a blood transfusion. Hepatitis B is also transmitted sexually, which of course is not a risk in newborns. (There is also a very slight theoretical risk of transmission through close household contact with someone with hepatitis B).
Hepatitis B vaccine is part of the routine vaccination series in children; they need 3 doses to complete the series. It is given to newborns to prevent transmission if the mother has it, and because it was decided to make it part of the infant vaccination series. This was decided because the vaccine has few side effects, immunity is permanent, and because it would be difficult to vaccinate older children when they become at risk for the disease (when they become sexually active).
The vaccine dose given in the hospital has now become an issue because all the combination vaccines used in infants contain a dose of hepatitis B. Most pediatricians and parents want to use combination vaccines because they can greatly decrease the number of injections given to babies. However, what this has meant is that the dose given in the hospital has become an extra dose, and babies are now getting 4 doses when they really need only 3 doses. In addition, almost all mothers are now tested for hepatitis B, and the baby needs the shot only if the mother is positive. If the mother does not have hepatitis B, and no one else in the household has it, then the baby does not need the vaccine in the hospital. If the mother’s hepatitis B status is not known, then the baby should receive the vaccine.
The American Academy of Pediatrics and the Advisory Committee on Immunization Practices (the body that makes official vaccine policy for the U.S.) finally recognized this fact in mid-2004, and stated that the dose in the hospital is optional if it is known that the mother does not have hepatitis B. Unfortunately, most hospitals continue to give it routinely without even considering this issue. In 2006, the panel reversed itself and stated that the vaccine must be given unless the doctor orders otherwise and puts the mother’s negative lab report on the baby’s chart. This, of course, ignores parental rights to consent to immunization, and I have not seen any hospitals adhering to this recommendation.
If you are sure that neither the mother nor any close contacts have hepatitis B, then consider not giving the baby the vaccine in the hospital. Be forewarned; the nurses at the hospital will have you sign the consent form for the shot before the baby is born, along with all the other paperwork, sometimes without explaining what you are signing, so if you want to skip the vaccine or discuss it with the pediatrician first, you have to first refuse the vaccine and not sign the consent form.
The vaccine does seem to be very safe and does not cause fever or any known side effects. It has been in use since the late 1980’s and does not currently contain mercury preservative (thimersol).
Cord Care
Until recently, it was standard practice to apply antiseptic (usually a dark purple solution) to the umbilical cord remnant because some babies would get infections at the base of the cord, which could be quite serious. Parents were also instructed to apply alcohol to the base of the cord several times a day until the cord fell off and the area healed. Paradoxically, for the cord to fall off and heal properly, bacteria are required, and treating with antiseptic and alcohol delays the process. In recent years, with improvements in hygiene and infection control, studies have suggested that the antiseptic and alcohol treatments are not necessary, and that the cord will fall off and heal faster if the cord is allowed to dry naturally. Although there is still some controversy regarding this practice, it has become very trendy lately for hospitals to let the cords dry naturally, without applying antiseptic, and for parents to be instructed not to apply alcohol. This has become standard practice at our local hospitals. If the cord is not treated, you need to be especially careful about looking for signs of infection, which are described in the next section.
Circumcision
If you have a boy and chose to have him circumcised, then the OB will usually perform the circumcision prior to discharge. The baby will need to urinate at least once before going home. The nurses will give you instructions on how to care for the circumcision (and you can also read about it here in the next section).
Hearing Screening
Hearing is essential to normal language development, and the first two years of life is the critical window for language development in the brain. Often, a hearing problem is not detected until language development is noticeably delayed, and earlier intervention can help to insure normal language development. The sooner hearing loss is detected and treated, the better the outcome. As a result, there has been a major public health movement for screening the hearing of all babies. The screening is done in the hospital after delivery and is painless and has no side effects. Virtually all hospitals in Georgia perform hearing tests on all babies born there. If the test is abnormal (usually because a good reading cannot be obtained on one ear), then the baby will have further testing done in the first few months of life.
State newborn genetic screening tests (PKU test)
The newborn screening test, often called the PKU test, is a program for newborn babies that tests for a variety of serious disorders and diseases. These diseases are generally treatable if detected early; however, children with these disorders do not show any signs of them until brain, liver, or other organ damage has already started to occur. That’s why a screening program is necessary, because the disease is not clinically detectable at first. By detecting the disease early and starting treatment, in most cases death, mental retardation, and/or physical disabilities can be avoided or lessened.
The majority of conditions for which babies are screened are metabolic diseases, genetic conditions in which the body cannot correctly break down and process certain sugars, proteins, or fats. In many cases, treatment is as simple as modifying the person’s diet. It is estimated that as many as 1 child in 3,500 is born with one of these conditions. In addition, most states screen for sickle cell disease and several other non-metabolic diseases such as congenital hypothyroidism.
All states have a newborn screening program which tests for some of these diseases; however, which diseases are tested for varies widely from state to state. Babies in Texas are screened for five diseases, while those in Mississippi are screened for over 30. Georgia currently screens for 25 conditions, including: phenylketonuria, galactosemia, maple syrup urine disease, homocystinuria, tyrosinemia, biotinidase deficiency, medium chain acyl-CoA dehydrogenase deficiency (MCADD), congenital adrenal hyperplasia, congenital hypothyroidism, and sickle cell disease. The MCADD screening was added in January, 2005, and 15 more were added using tandem mass spectrometry in January, 2007. Georgia now screens for the 25 most recommended diseases.
In Georgia, all babies are screened in the hospital before being discharged. If the test is done before the baby is 24 hours old, the test also has to be repeated within the first week of life because some of the tests are not as accurate until the baby is 24 hours old. The repeat test is collected in your pediatrician’s office.
Expanded newborn screening
There are many metabolic diseases, and more are being discovered all the time as a variety of specific defects are discovered. Fortunately, most of these diseases are very rare. PKU, which stands for phenylketonuria, is one of the more common diseases, and a test for it was developed in the 1960’s. It is the first such disease for which a test was developed. Since then, tests for a handful of other diseases have been developed.
Now, thanks to a technology called tandem mass spectrometry, over 30 disorders can be tested for at once, all from just a few drops of blood! This has become a hot political and public health topic nationwide in recent years, and there is a lot of debate going on now about whether it is cost-effective to screen all children and how expanded screening should be funded. Thirty states are now performing tandem mass spectrometry. Some of the diseases tested for by tandem mass spectrometry are more common than some diseases currently screened for in Georgia.
Parents do have the option of having their babies tested, at their own expense. Several companies and hospital research labs are currently offering the test to the public. Parents can contact the lab to obtain the materials; we will collect the blood and get the results of the test. The test is easy to perform, involving just a heel stick, and costs less than $100. Our office has the test kits for the Pediatrix screening here in our office, and you do not need to order them from the company if you choose to have your baby tested by them. We generally recommend that parents use Pediatrix screening. We have information on all the tests available on our website and in our office.
The only known drawback to testing, besides the cost, is that a test is occasionally falsely positive, which requires further testing for confirmation and can cause some parental anxiety while waiting for the confirmation.
The pediatrician’s exam
At some point, usually within 24 hours of delivery, we (or whatever pediatrician you have chosen) will come to examine your baby and to answer any questions you may have. The pediatrician will do a complete examination of your baby from head to toe. We always try to do the exam in the room with you, but sometimes we do it in the nursery. We will also review the records of your pregnancy and delivery to see if the baby has any risk factors for infection or other complications and to see if any special tests are needed. We will also let you know then when the baby should be seen in the office. This is usually during the first week of life, especially if you are breastfeeding and/or it is your first baby. Also, if you go home before the baby is 24 hours old, the Georgia newborn screening test has to be repeated in the first week.
Other labs and tests
Sometimes other labs and tests are done, depending on how your baby is doing, risk factors for any diseases or infections, or because of findings when the doctor or nurses examine your baby. Most commonly, blood counts and blood cultures are done to see if any bacterial infection is present. Risk factors for infection include mom being colonized with group-B streptococcus (see Group-B strep above), if mom’s water broke more than 18 hours before delivery, or if mom or baby have a fever. Other common tests are blood sugar (glucose) levels (especially if the baby is large), and bilirubin levels if the baby looks jaundiced (see jaundice).
Your time in the hospital
Get some rest! Take time to eat a healthy diet and get your strength back. Enjoy having the nurses take care of you, and take advantage of their help and advice as you learn to take care of your baby. If you are breastfeeding, the nurses and lactation consultants are wonderful resources and can really get you started off on the right foot and can make a real difference in your breastfeeding experience and success. The hospital is likely to have breastfeeding and/or newborn care classes. You should take advantage of these, especially if you are a first time parent.
Discharge and follow-up
When should your baby go home? The minimum requirements are that the baby is feeding well and has peed and pooped at least once. Many experts still recommend that the baby stay in the hospital at least 48 hours, although this practice is becoming less common. The baby must stay in the hospital at least 24 hours after birth. In the absence of any complications or risk factors for infection or severe jaundice, the baby can usually go home between 24 and 48 hours of life, although 48 hours is still preferable.
As discussed above, we will usually see your baby during the first week of life, usually within 2-3 days after you leave the hospital. If there are concerns or complications, we may see the baby the day after you leave. At this visit we weigh the baby to be sure she is not losing too much weight, assess feeding, look for jaundice, perform an examination, and repeat any tests that need to be repeated. If you go home before the baby is 24 hours old, then she will need to be seen at the doctor’s office within 2 days after discharge.
