What happens in the newborn nursery…goes home with you

I have a confession. When my first baby was born, the nurse said she was going to check the bilirubin, and I thought it was somebody’s name. You know, like “Billy Reuben.” I wasn’t stupid; I was a graduate of a respected university and a Naval officer, training to operate nuclear reactors. But obviously, I had no idea who/what bilirubin was or why it mattered. I didn’t bother asking; I just pretended like I knew what she was talking about. And I think that’s the position a lot of parents are in when they have their first (or fourth) baby–they don’t really understand what’s going on, but they’re afraid to ask. (Thanks for listening. I feel better now.)

1. Introduction

Sometimes Most of the time, doctors do a pretty crappy job explaining these things to parents. The newborn nursery is a busy place with a high turnover rate, and there’s a lot of pressure to keep moving along. And frankly, new parents usually do a crappy job listening–mostly because they’re stressed/hormonal/sleep-deprived/emotional/distracted/drugged/etc. It’s really not an ideal setting for communication. And that’s why I wanted to take some time–before you’re in active labor–to explain what goes on with your baby after delivery, and the reasons behind the things that we do.

I’ve had to break this post up because of the massive amount of information. Really, I could write a book about it (and I probably will). In other posts, I’ve discussed some big issues in newborn care. If you haven’t read them yet, I would strongly encourage you to.

I’m intentionally leaving out everything prior to delivery; that’s clearly the domain of my OB/GYN colleagues. I’m also assuming at this point that you have elected to deliver in a hospital setting. There’s about a 2% chance that this assumption is false, but many of these topics still apply. The home birth/birthing center/hospital conversation is a good one, and I promise to address it soon. Even within a hospital setting, there are many variations on this theme. What is routine in one isn’t always done in another, and that’s ok. In many of these cases, there are several equally good ways of doing something. And in the lack of evidence that one way is clearly safer or more effective, there’s room for variation.

2. A word about birth plans

Birth plans are a great tool for you to think through how you’d like this special day to go. If you have strong preferences, be sure to let your nurses and doctors know; sometimes we just get in a groove and forget to ask. We need to do a better job trying to accommodate these requests when possible. But remember, it’s not a vacation. I know I’m going to take some heat from the natural childbirth crowd about “medicalizing” the birth process, but it’s important to remember that a couple centuries ago, a woman had about a 1/100 chance of dying during childbirth. The babies didn’t fare any better–as a fellow pediatric blogger wrote, “Old cemeteries are littered with tiny little headstones for little dead children.” Clearly, we’ve come a long way since that time, but labor remains one of the most dangerous events for both women and babies.

Sorry if I scared you, but it’s something you need to recognize–not so you worry about it, but so you remember that the primary goal is to get mom and baby through the process safely. No matter if you deliver at home in your bathtub or in a sterile OR, sometimes things don’t go as planned. Don’t be shocked if your birth plan goes down in flames; just be grateful everybody is safe.

3. Resuscitation

I know–not a happy topic, but you need to know that it happens. Most likely, your baby will be fine. But some of them aren’t–initially–even the ones who are doing well just a few minutes later. In fact, about 10% of infants need some kind of help to start breathing. It’s usually not a big deal–the first three steps are “warm, dry, stimulate” (not “bag, compress, intubate”). With just that assistance, most babies will perk up and start breathing. And of those that don’t, the vast majority respond well to brief assistance with breathing. It’s pretty rare that we have to go further than that. But if the need arises (and you’ve chosen to deliver in a facility with a NICU), we’re really good at that, too.

Again, I’m not trying to scare you. I just want you to know that this is pretty common, so if a team rushes in to take a look at your new baby, try not to freak out. They are there to help, and it doesn’t mean she’s dying. Chances are, she’ll be just fine.

Along the way, we assign a score called the Apgar score. It’s a number, from 1-10, which is based on the baby’s activity level and how much coffee the delivery team has had during the shift. The Apgar score is assigned at 1 and 5 minutes after birth. I’m not convinced that they are all that helpful. It’s certainly true that infants with lower activity levels (including heart rate and breathing) will likely need more assistance; I’m just not sure we need a score to tell us what we had already decided. What we do know is that–assuming your kid does well immediately after birth–the Apgar score has nothing at all to do with his future athletic prowess or his SAT scores. It’s a tool to evaluate an infant in the immediate postpartum period–nothing more. So stop comparing your kid to mine; mine both got straight 10’s.

4. Weight and measurements

Obtaining a birth weight is one of the most important things we do after a baby is born. If it’s too high or low for the baby’s gestational age, it lets us know that the infant could be at risk for a variety of complications. It also gives you something to write in your baby book or post on Instagram. But I’m not all that concerned about whether your baby was 7 lbs 4 oz or 7 lbs 6 oz. (Honestly, I despise the English system for newborn weights because it makes it nearly impossible to do math.) As long as the birth weight is normal(ish), the exact number doesn’t matter all that much. Except on Instagram.

What is important is the trend in an infant’s weight over the first few days. Having an accurate birth weight provides a baseline for comparison. It’s normal for infants to lose weight over the first few days (usually around 5-12%), and we typically allow them about 2 weeks to get back to birth weight. If they lose too much or don’t start growing fast enough, it is usually a sign that they aren’t feeding well. (If you want to see how your baby’s weight trend stacks up, there’s a fantastic tool here.)

While we’re checking the weight, we measure the infant’s length and head circumference as well. Unless they are impressively abnormal, we don’t tend to worry too much, but they provide a baseline for comparison.

5. The first exam

This is the pediatrician’s moment to shine…or fail miserably. The newborn exam is different from most physical exams that we perform. There’s a handful of things that we don’t tend to look for at other times–things like counting fingers and toes, or making sure there’s an anus (sometimes there’s not). We look for potentially life-threatening issues, abnormalities that are known to be associated with certain syndromes, and things that would be poor form to miss (like the anus thing).

There’s a lot more that goes into the exam itself, but one of the most important things we do is talk to the parents while we do it. Parents haven’t known this kid for very long, and they usually have lots of questions: What are those red spots? (A normal baby rash.) Why does his head look like that? (Because it was crammed in your pelvis.) Is it ok if his feet are purple? (Yes.) Why did you just hold him up and drop him? (Really, it’s a thing.) And my favorite: What color do you think his eyes will be? (No clue. Probably brown. Or green. Or blue.)

But seriously, it’s their brand new baby, and parents just want someone to tell then everything is ok. Before I unwrap the baby, I ask if there’s anything they’ve seen that they’re concerned about–so they don’t think I’m asking because I saw something. Then I methodically examine the baby, pointing out every little thing that I think they might worry about, and reassuring them (if appropriate). Done correctly, the newborn exam is a great time to build trust with a family and ease a lot of anxiety–in addition to potentially discovering something abnormal. Done incorrectly, it’s easy to miss things. It’s super embarrassing the next day when they ask, “So when are you going to remove her extra finger?” (Her extra what?) Or the anus thing. It pays to be thorough.

6. Hearing screen

Hearing loss is common–between 2 and 4 out of every thousand children, and it contributes to speech and language delays. In many cases, hearing loss is at least partially correctable; the earlier it is picked up, the better the outcome. The hearing screen is a quick, non-invasive test that can have a huge impact on a child’s development.

There are two types of newborn hearing screens available, but they both involve placing ear plugs in the infant’s ears, playing soft sounds, and evaluating some type of response. Infants who don’t pass this test are referred to an audiologist for further evaluation. As with any screening test, we over-call on purpose so we don’t miss anyone with actual problems. A large percentage of infants who don’t pass the hearing screen actually have normal hearing at the followup appointment. Children with true hearing loss are typically sent to an ENT for evaluation and treatment, which could mean hearing aids or surgical intervention, depending on the cause.

7. Newborn screen

The newborn screen is a test that looks for a number of diseases. There is a core group of 21 conditions that are federally mandated, but the exact panel of tests differs by state. The big ones are cystic fibrosis, sickle cell disease, thyroid or adrenal problems, and metabolic diseases. A few states (including my own) have recently introduced testing for severe combined immune deficiency–a fatal immune system defect that can be cured if caught early. What all these diseases have in common is that we are able to detect them at birth, and intervening early makes a difference. It’s very rare for families to decline the newborn screen, and I wouldn’t recommend it. It has one of the higher benefit/risk ratios of anything we do in the nursery.

The test is performed by pricking the infant’s heel and placing several drops of blood on a paper card, which is then sent to your state laboratory. This is usually done after 24 hours of life and before discharge from the hospital. Usually within 2 weeks, your child’s doctor should get a copy of the results. If you haven’t heard anything by your baby’s 2-week visit, ask about the results. Most of the time, we just don’t tell parents about the results because they were normal. Occasionally, they get sent to the wrong office or need to be recollected. Rarely, there’s an abnormal result that never makes it to the doctor or the family. So give it a couple weeks, and then ask. It’s part of being an active participant in your child’s health, and we can all use the reminder. If the conditions are important enough to test for–which they are, it’s just as important to know the results.

8. Congenital heart disease screen

Another universally-recommended screening test is the cyanotic congenital heart disease (CCHD) screen. About 18 in 10,000 babies are born with heart defects that cause cyanosis, or low oxygen levels in the blood. These infants need urgent evaluation by a cardiologist, and many of them will need surgery. The test is simple and non-invasive, involving check oxygen saturations in multiple extremities. A large difference between the numbers can indicate a heart defect that needs further evaluation. Honestly, it’s not a fantastic screening test, because it will miss 25% of children with these heart conditions. But it does pick up 75% of them, with very minimal cost or risk. It’s not perfect, but it’s certainly worth doing.

9. Bilirubin

I’m going to cover this extensively in a later post, because this topic extends beyond the newborn nursery. But I want to make sure you understand why we do this test–mostly because I didn’t.

Bilirubin is a molecule that comes from the breakdown and recycling of red blood cells. It’s totally normal for this level to rise over the first few days. The concern is that, at extremely high levels, bilirubin can get deposited in the brain and cause permanent brain damage–a condition called kernicterus. There are a variety of risk factors for this condition that I’ll address in a future post, but it is extremely rare in developed nations. It still happens–and when it does, it’s devastating–but it’s rare.

Before discharge from the hospital, we check every baby’s bilirubin level. Sometimes, it’s totally fine and we never have to check it again. Often, we need to follow it in a day or two to make sure it’s not rising too fast. Occasionally, we need to do something about it. That “something” could be helping with breastfeeding or supplementing with formula (because the more a baby eats, the more he pees and poops, and the more the bilirubin level drops). Or it could involve placing him under phototherapy, a bright blue light that converts the bilirubin under the skin to a form that is more easily excreted.

Newer evidence makes it seem likely that we are over-treating this condition; I’ll write more about this later. For now, our current system is very good at preventing neurological damage and lifelong disability. So until we figure out a safe way to back off, it’s best to stick to what we know.

10. Lactation support

There may be hospitals out there without lactation consultants, but I would suspect that these are rare. Most hospitals that deliver babies employ independent board-certified lactation consultants (IBCLCs) to assist mothers with breastfeeding. Strangely, the most natural way to feed a baby doesn’t always come naturally, and a good IBCLC can be a vital part of breastfeeding success. They can help with latching, positioning, emotional breakdowns, and a variety of other concerns. Typically, their services are available after you go home as well, but this depends on your location. It’s worth getting a phone number to call if you need them a day or two later. With the great support available today, the vast majority of mothers can experience breastfeeding success.

It’s rare that a mother truly can’t breastfeed. But for many, the time, effort, and emotional stress get overwhelming, and they decide to switch to formula. Some moms simply choose not to breastfeed. While it’s true that breastmilk has health advantages over formula, it really bothers me when women who can’t (or choose not to) breastfeed are criticized for this decision. Formula doesn’t, and probably never will, match the nutritional quality of breastmilk. But it’s a very good substitute, and many of us grew up on it and did just fine. If we cared half as much about what a child eats after his first birthday as we do for the first 12 months, our kids would be a lot better off.


Don’t forget to check out my post about the most controversial things that happen in the newborn nursery (hepatitis B vaccine, vitamin K shot, circumcision, eye ointment, and the first bath). I didn’t cover them again in this post, but they’re important topics. And if the umbilical cord has you stumped, you’re not alone. In upcoming posts, I’ll discuss the big deal with bilirubin as well as what happens after you go home. Follow along on Facebook or Twitter for updates about future posts.

As always, I hope you learned something that make parenting a little better. Thanks for reading and sharing!

-Chad