On a late morning on the first day of February, Howard Drake found his peaceful slumber broken, and he was none too happy about it.
Born just 12 hours earlier at UCHealth University of Colorado Hospital, Howard had been snoozing contentedly in the arms of his mom, Kelly, while dad David looked on. But now it was time for his first bath. Josi Berry, RN, a direct-care nurse with the hospital’s Labor and Delivery Unit, laid Howard in a bassinette and pulled back a small section of the blankets that swaddled him. While Kelly and David watched closely, Berry dipped a towel in a basin of warm water and gently cleaned the upper part of Howard’s body.
Howard, who entered the world at a solid nine-plus pounds, showed his lungs worked just fine, protesting as Berry methodically bathed him, exposing only a portion of his body at a time to make sure he stayed warm. Meanwhile, Howard got plenty of comfort from Kelly and David, and he quieted contentedly after Berry removed his tiny cap and gave his full head of hair a wash.
A baby’s first bath is nothing new, of course, and Kelly and David, who already had a boy and a girl, weren’t strangers to the routines of a new arrival. But the bathing experience with Howard was a little different.
Had he been born a year ago, Howard would have been whisked away for his first bath shortly after he arrived. The Birth Center admissions nurse would have cleansed his body of the slick white substance called vernix that covered his body. Only after that task and checks of his vitals would Howard have returned to his mother’s arms. That had been the experience for Kelly and David and their two other children.
Hold that bath
The new protocol, implemented in the Birth Center last April, delays the newborn bath for at least eight hours in most cases. Berry, who spearheaded the change as part of her credentialing project for UEXCEL – the clinical ladder for nurses at UCH – said evidence shows that the extra time produces important benefits for both mom and baby. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) has supported the practice since 2015.
First, the vernix may look messy, but it is a natural protective layer that helps to ward off infection and keep the baby’s skin soft and supple, Berry noted.
Christine Gold, MD, attending physician in the Birth Center’s Newborn Nursery, added that leaving amniotic fluid on the skin provides another comfort for newborns suddenly adapting to a strange new world. The fluid on the infant’s hands, Gold explained, is similar to colostrum, the initial protein-rich breast milk mothers produce. Leaving the fluid undisturbed may therefore promote better breastfeeding, Gold said in an email. Infants are also at less risk of hypothermia and hypoglycemia (low blood sugar) when bathing is delayed, she said.
Importantly, delaying the bath improved the Birth Center’s adherence to giving mom and baby the “golden hour” of skin-to-skin contact that is crucial to bonding and beginning to establish the breastfeeding routine, Berry noted. Previously, this important period had sometimes been interrupted in the eagerness of parents and nurses to get the bath out of the way – a missed opportunity, both physically and emotionally.
“We’ve seen that skin-to-skin contact after birth helps to stabilize the baby’s temperature,” she said. “They have a chance to start to feed and to bond. It all helps to normalize their new environment.”
That squared with Kelly Drake’s experience. “I think the extra hour helped,” she said. “We had a little more time with [Howard]. It seemed more natural and not such a process after he came out.”
Delayed bathing also gives direct-care nurses and advanced care practitioners (ACPs), who are responsible for it, an important window of teaching time with parents, Berry said.
“The time at the bedside is hugely valuable for nurses to talk through skin care, drying, diapering, crying, and comforting their babies,” she said. “Involving parents in the bath is confidence building. It helps them to feel empowered and confident in doing the care for their babies.”
Berry said preliminary data from the Birth Center indicate that the delayed bathing policy may be having a positive effect on important measures of infant health. For example, the average LATCH score, which measures the success of breastfeeding among mothers who choose to do it, has improved in the first 24 hours from 7 to 7.7 on a scale of 1 to 10. Meanwhile, the percentage of infants whose mothers wanted to breastfeed but needed nutritional supplements declined in the first three months after the change to 31 percent from 43 percent and has remained at that level, Berry said.
It was far too early to draw any conclusions about how Howard would do with breastfeeding as he got his first bath, of course, but early signs were promising. As he fussed, Kelly offered him her finger, which he eagerly accepted. He also seemed receptive to breastfeeding during the golden hour, Kelly said.
“He figured it right out,” she said.
In adopting the new policy, the Birth Center followed the leads of UCHealth Poudre Valley Hospital and Memorial Hospital, and Berry drew on their experience. But any clinical change requires laying a solid groundwork and preparing staff to modify their workflows. Some nurses, for example, were skeptical about not getting newborns into warmers quickly and worried about adding a new task to already busy schedules.
Berry addressed these and other questions with education about the benefits of delayed bathing for both newborns and parents that she gleaned through reviews of the medical literature. She produced a video in which she demonstrated the proper bathing technique and put together skills labs. “I did a lot of baths, with coworkers,” she said.
Not surprisingly, the routine needed tweaks along the way. A bedside bath requires a lot of supplies, including towels, hats, soap and combs. Gathering it all could have been quite a time drain, so ACPs put together ready-to-go bath kits. Admission nurses use cards placed on bassinettes to check on which infants need their baths and document baths that were completed and when. To address possible hygiene concerns, the bathing nurse pulls on gloves before handling newborns.
The unit also took care to avoid pushing the policy on parents, Gold stressed.
“Occasionally, a parent is confused about why their baby’s bath has been delayed,” she said. “However, with a small amount of education, most parents express understanding of this change on our unit. It is still ultimately a parent’s choice as to when their baby is bathed.” Babies born to mothers with hepatitis or HIV infections still receive a bath immediately, she added.
Nearly a year after implementation, Berry called the delayed newborn bathing policy “completely normalized” with the unit committed to handling work when the time fits for patients, not the other way around.
“We’ve sacrificed some of our ability to ‘check boxes’ on tasks as opposed to being with patients and being present,” she said. “Spending quality time with patients and talking with them about their newborns should not have to wait until the time they are discharged.”