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Promoting a Culture of Safety in Mother-Baby Units.

For nurses to provide safe and competent care for new mothers and their babies, the appropriate nurse-patient ratio must meet the guidelines as determined by professionals. The Association of Women's Health and Neonatal Nurses (AWHONN) published a Guide for Professional Registered Nurse Staffing for Perinatal Units (2010) which contains specific guidelines for mother-baby staffing. [Note that only nurses who are members of this organization have the authority to obtain a copy of this publication.]

AWHONN is headquartered in Washington D.C. and is a leader among the nation's nursing associations caring for women and neonates, serving more than 22,000 health professionals. Its members are committed to delivering superior health care to women and newborns in hospitals and ambulatory care settings. The rich diversity of members' skills and experience make AWHONN the voice for women's health and neonatal nursing. Through the knowledge, skill and expertise of its members, AWHONN provides education, and resources aimed at promoting the health and safety of women and newborns (AWHONN, 2010). The prevention of harm is the ethical responsibility of the bedside nurse, regardless of setting. Provision 3 of the Code of Ethics for Nurses states, "The nurse promotes, advocates for, and protects the rights, health and safety of the patient" (ANA, 2015). When caring for the new mother and her baby, there are two patients to protect from injury. A baby being dropped or a new mother letting her infant fall are things nurses are ethically responsible for preventing by promoting a culture of safety. Adequate staffing and the provision for care of the newborn when the mother or family member is unable to is nursing's responsibility.

The organizations who endorsed the "Guidelines for Professional Registered Nurse Staffing for Perinatal Units," including the American Academy of Pediatrics, the American College of Nurse-Midwives, the ANA, and the National Association of Neonatal Nurses, support the recommendations for safe nurse staffing. Adequate staffing is critical to providing safe nursing care to mothers and babies. Models of staffing that may be appropriate for medical-surgical units are not applicable to perinatal care. Traditional staffing models of "hours per day" or "midnight census" are not applicable in planning perinatal staffing because they do not consider the dynamic nature of caring for women during labor and birth, the first few hours after delivery, the surgical deliveries, and the needs of the newborn following birth as it transitions to extrauterine life. The high frequency of admissions, transfers, and discharges in the areas of labor and delivery, motherbaby, high risk perinatal, and neonatal ICU, have implications for staffing needs. A review of staffing recommendations illustrates the influence of these factors.

After cesarean birth, patients need assistance with newborn care, especially in the immediate recovery period. They should not be required to keep their babies in their room if they do not feel up to it and/or a support person is not available to stay with them. Until the new mother recovering from cesarean birth is no longer receiving pain relief via PCA pump or epidural catheter, babies should not be left alone in mother's arms without nursing personnel or support people in attendance. The presence of a family member or nursing staff will reduce risk of a baby falling from the mother's arms or of a mother falling asleep with the baby in the bed. This recommendation applies to mothers who have been given medication for sleep and/or pain medication containing narcotics which increases the risk for baby drops and falls.

Another factor to be addressed is the fact that many babies are delivered prior to the full gestational age of 38 to 40 weeks. Any gestational age below that is considered "near term" or "pre-term" (Gills & Boyle, 2016). Some sources consider a 38-week intrauterine pregnancy to be near term, and 39-40 weeks to be term. A 2016 study is considered the first population-based countywide assessment of neonatal morbidity among early-term infants based on individual medical records in the United States (Gills & Boyle). The results support the need for an increased awareness among health care providers that even though babies born at 36, 37, or 38 weeks frequently are considered almost term, they are still physiologically immature. These early term babies were at significantly higher risk for adverse outcomes for low blood sugar, respiratory difficulty, or needed antibiotics requiring admission to the neonatal ICU (Gills & Boyle, 2016).

After evaluating admission patterns among the newborn infants between 37- and 41-weeks' gestation, the researchers found these early-term infants were more likely to suffer morbidity within a few hours of birth (Gills & Boyle, 2016). To verify these patterns they undertook a larger, countywide study, conducting an analysis of births at four different hospitals. These data showed similar patterns. The data also indicated that early-term babies delivered by cesarean section were at a 12.1% higher risk for admission to the neonatal unit, compared with full-term babies and a 7.5% higher risk for morbidity compared with term births (Gills & Boyle, 2016).

These findings are concerning to couplet care nurses, as these patients and their babies are admitted to the typical couplet care unit two hours after delivery. Safety is a serious concern. If the nurse is in the process of discharging a couplet, which is often time consuming, does the nurse have the time to adequately monitor a new couplet? Can the nurse who is providing nursing care to three couplets safely take on the care of a new couplet? These are concerns which must be addressed for the safety of both the maternal/infant dyad and the nurse providing care. Perinatal nurses should remember that when there is a negative event, the first question asked by the lawyer for the plaintiff often is "What is your nurse/patient ratio?"


American Nurses Association. (2015). Code of Ethics for Nurses-with Interpretive Statements.

AWHONN. (2010). Guide for Professional Registered Nurse Staffing for Perinatal Units.

Gills, JV, & Boyle, EM. (2016). Outcomes of infants born near term. Archives of Diseases in Childhood, 102 (2), 194-198. doi: 10.1136/archdischild-2015-30958410.1136

Mary F. Wessinger, RN. MN, BC
Table 1

Patient Population   Guidelines from 2007     Recommendations in 2010

Healthy mother-baby  1 nurse to 3-4 couplets  1 nurse to 3 couplets
Cesarean birth       Same level of care as    No more than 2 couplets on
                     a patient having major   day one
                     abdominal surgery
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Author:Wessinger, Mary F.
Publication:South Carolina Nurse
Date:Mar 1, 2019
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