Nightime Nightmares 1631

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Nighttime Nightmares
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Melrose-Wakefield Hospital

• 10 miles north of Boston
• 1200 births per year
• No VBACs
• CS rate 20 primary, 20 repeat
• Culture mix caucasian, asian, indian, haitian,
  hispanic
• Socioeconomic middle-to-low income
• 25 WIC participants
• Average age of nurses 50

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Baby Friendly Hospital Certificate of Intent 2007

• In 2007 our Chief of Pediatrics, Dr. Tien-Lan
  Chang, proposed the Baby Friendly Hospital
  Initiative to Melrose-Wakefield Hospital
  Executive Staff, and our journey began.

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Simply Stated

• Have a policy, know it, stick to it
• Train Staff
• Inform pregnant women about the benefits
• Help moms get started w/in an hour of birth
• Show moms how to maintain

1. Breastmilk only
2. Rooming-In
3. Unrestricted breastfeeding
4. No pacifiers or other artificial nipples
5. Provide or refer moms for postpartum support

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Step 7Rooming-In

• AKA
• How to Get Your Night Staff
• to Hate You

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What We Did.

• As we moved along w/ the steps, when we got to
  Step 7, we hit a wall.
• We decided that we would educate the staff, start
  with days (10-2).
• After about 9 mos w/o improvement on other
  shifts, we picked a full rooming in start date

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Rooming-In Starting Monday, March
23rd 10am-2pm Nursery closed except for
admissions special circumstances
Help us to reach our Baby Friendly Hospital goal
by encouraging rooming-in. Rooming-In should be
the standard babies in nursery, the
exception. Teach your families about rooming-in.
You can direct them to the information sheet on
the front of the yellow folder /or the
breastfeeding folder if they have
questions. Also if mother is not with baby, only
the designated banded person can be left alone
with the baby. Rooming In is expected for all
healthy mothers and babies. Mothers who are
unable to respond to their babies will not be
expected to Room-In (C/section lt 24 hours, or
mom is ill) Thanks, Baby Friendly Task Force
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At a fall OB Committee meeting, towards the end
of the meeting, we mentioned we would be moving
to the Rooming In Model of Care in January. This
was not well received.
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The Rooming In Summit

• With input from our CNO, The Rooming In Summit
  was planned
• Evening in November, dinner provided
• Guest Speakers Lori Pugsley, MGH, Ruth Elio,
  Winchester Hospital, and .patient, MWH
• All Staff Invited and encouraged to attend.

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Melrose-Wakefield Hospital Maternal-Newborn
Service
What is Rooming-In Why are We Doing
It? Beginning in January, 2010 MWH
Maternal-Newborn Service will be transitioning
to the rooming-in model of mother-baby care.
Healthy mothers and babies will be cared for
together in the same room. Come and join us for
dinner and discussion at the Rooming-In
Summit Thursday, November 12th 2009 6-8
PM Perkins Lecture Hall RSVP mfoley_at_hallmarkhealt
h.org
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Rooming In Summit
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Chief Nursing Officer, Nancy Gaden
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Mary Foley, Lactation Program Coordinator, MWH
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Director Maternal Newborn Service, MGHLori
Pugsley
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Lactation Consultant, Winchester HospitalRuth
Elio
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Panel Question and Answer / Discussion
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How it Helped

• Attended by physicians and nurses together
• Everyone hears the same message
• Allows a peek into another practice style
• Helped LCs to not feel like the crazies
• Influence of MGH was effective
• Influence of competitor was effective
• RNs were able to ask tough questions and get real
  answers

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Rooming -In Heart to Heart, From the Start
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Working the Night Shift

• Twice over the past 2 years I have worked a full
  month of nights
• I encourage our LCs to work off shifts when they
  can
• Role modeling
• Support
• Scripting
• Building Relationships

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What Do We Say?Ideas For Staff

• We really encourage you to keep the baby in with
  you. Why dont you try keeping the baby here,
  and if you find you cant sleep, then ring your
  light, Ill come right in.
• Baby needs you to help him/her transition to life
  outside the womb
• Baby needs a lot of frequent feedings, his tummy
  is small
• DAYTIME PRACTICES
• Mom sleeps when baby sleeps
• Shades down, lights off for daytime sleeping
• Serenity Time
• Power Naps
• Limit Visitors
• Dad/Mom take turns
• Baby will sleep better when in room. Nursery is
  bright, noisy, like daytime. Baby is not
  necessarily sleeping in the nursery
• More feeding now more milk later
• If baby could talk he/she would rather be with
  you
• Babies cry less when with mom

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Patient Education

• 
   
• Rooming-In
• We would like to strongly encourage you to keep
  your baby
• with you throughout the day and night.
• Rooming in has the following advantages
•  1. Baby sleeps better and cries less. It is less
  stressful for the baby.
• 2. Your milk comes in sooner.
• 3. Baby gains weight better.
• 4. Baby develops less jaundice.
• 5. Baby feeds more often.
• 6. You will be more likely to exclusively
  breastfeed and continue to breastfeed longer.
• 7. You can get to know your baby better.
• 8. You are better prepared to take care of your
  baby when you go home.
• 9. You learn to recognize your babys feeding
  cues.
•  

• In Hospital

What about sleep? 1. Mothers have the same amount
quality of sleep when rooming in as when the
baby is out of the room. 2. Get your sleep in
chunks sleep when your baby sleeps. 3. The
daytime is for sleeping, too. Limit distractions
and visitors. 4. Learn to nurse in the side-lying
position so you can rest while baby feeds!
Breastfeeding throughout the day and night in
the early days is associated with greater milk
supply and greater overall breastfeeding
success.   If you choose to have your baby fed
with formula during the night, you should be
aware of the following problems that may
occur   Less interest in feeding at the
breast Difficulty getting the baby to latch and
suck Uncomfortable over-filling of the
breast More interest in the bottle than the
breast  
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Rooming In Because the best place for baby is
with mom. ?
Rooming-In
Rooming-in means that your baby stays with you in
your room throughout your hospital stay. Why
is rooming-in best? Babies sleep better and cry
less Baby gains weight better You get to know
your baby sooner You are better prepared to
take care of your baby when you go
home What about sleep? Research shows mothers
often sleep better when Rooming-in than when the
baby is out of the room. What about special
circumstances? The nursery is available if you
should need assistance in special circumstances.


Having my son with me was a wonderful
experience. I felt closer to him every minute
and was glad I had him with me. Leanne

Baby will be with you throughout the day night,
except for short visits to the nursery for
medical procedures. The nursery nurse will be on
the maternity unit teaching and assisting you
with the care of your baby as needed.
Your baby is soothed by your voice, scent and
touch. Get to know your baby best
by Rooming-In.
My husband and I spent our entire stay at
Melrose-Wakefield Hospital with our son Dominick
in our room with us. The only time he was out of
the room was for his daily check ups and his
circumcision. It was the most rewarding
experience for us because we got to know our son.
Before we went home by ourselves we knew what
his cries meant and what all his noises meant.
Nicole
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Public NotificationLocal Newspaper
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Obstacles to Rooming-In _at_ Night

• Nursery
• Parent Fatigue
• Unrealistic expectations Staff/Parents
• Physicians
• Family/Friends/Father
• Hospital Procedures
• Low supervision/modeling
• Night Culture

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Nursery Open

• DPH
• Admissions
• Phototherapy
• Immediate Post Op C/S

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Nursery Door
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Parents are Tired

• Daily Interruptions
• Nurse
• PCT
• Dietary
• Pt Rounds
• Housekeeping
• Lactation
• Photographer
• Birth Certificate
• Pediatrician
• Obstetrician
• Visitors
• Social Worker
• Hourly Rounding

• Labor
• Inductions
• C/S
• Working throughout pregnancy
• Moving Weddings
• Siblings
• Unit Interruptions

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Unrealistic Expectations

• Mother will sleep through the night
• Baby will eat on schedule
• In Reality..
• Infants have a high percentage of REM sleep
• Babies have shorter sleep cycles
• They enter sleep through REM cycle (20 min)
• Sleep studies define sleeping through the night
  as midnight to 5 am for infants
• Sleep resembles feeding Small Frequent Meals
  Short Frequent Naps

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Why?

• Needs are intense, but ability to communicate
  these needs is limited
• Light sleep is protectivecrying is the babys
  way of communicating something
• REM sleep is prevalent at times of brain
  development
• (ex Simple animals have mostly non-REM sleep.
  Human fetus has mostly REM sleep)

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Two Goals

• Increase Infant Sleep
• Keep Baby Close
• Wait for Deep Sleep to Put Baby Down
• Think About Routines
• Make Distinctions Between Day Night Feedings

• Increase Parent Tolerance
• Educate, Educate, Educate
• Babies Sleep, Eat, Cry
• By 3 wks awake 10 hrs
• 70 settle by 3 months
• Allow the Nightime Parenting Experience While
  Help is Available

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Physicians, Family, Friends, Culture

• Get your sleep in the hospital while you have
  the luxury of the nursery!
• Parent Sleep a Major Issue in first 3 months
• Educated physicians and offices by doing visits
  to every OB office speaking at OB meetings
• Newspaper Hospital Publications/Rooming-In

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Melissa
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Breastfeeding Increases Sleep!

• Doan, et al. Journal of Perinatal Neonatal
  Nursing, 2007
• 133 new parents _at_ 3 months
• Sleep was measured by diaries and actigraphy
  (wrist bands)
• Formula fed, breastfed and breastfed w/ bottle of
  formula in late evening were measured

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Results
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Hold Off On That Bottle.

• Using supplementation as a coping strategy for
  minimizing sleep loss can actually be detrimental
  because of its impact on prolactin hormone
  production and secretion. Maintenance of
  breastfeeding as well as deep restorative sleep
  stages may be greatly compromised for new mothers
  who cope with infant feedings by supplementing in
  an effort to get more sleep time

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Sleep Interrupted

• Quillan Glenn (2004), JOGNN
• 33 first time healthy mother baby pairs
• 13 breastfeeding, 20 formula feeding
• 4th week postpartum diaries
• Babies averaged 13.9 hrs sleep per 24 hrs
• No difference in total sleep time for moms, but
  breastfeeders had more total sleep periods (more
  interruptions, feels like less sleep)
• Moms averaged 5.8 hrs of sleep during usual
  sleep time but preferred 9 hours.

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Hospital Procedures _at_ Night

• Weights
• Bilis
• PKUs
• Vital Signs
• Hearing Screenings
• Baths

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7 of 16 Babies in Nursery
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Carolyn
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Low SupervisionFew Role ModelsNight
Culture
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Summary

• Educate! Physicians, Staff, Parents, Community
• Prepare in Advance
• Build relationships with night staff
• Positive reinforcement
• Expect change to be gradual
• Communicate expectations in a variety of ways
  (e-mail, direct, staff meetings, signs etc)

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Lets Make This Scene Obsolete!
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And This Scene Standard
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Thanks!