EXECUTIVE SUMMARY

A hospital faces a lawsuit after a newborn child smothered in the mother’s arms. The case illustrates the patient safety threats posed by leaving a baby with the mother soon after birth.

  • Efforts to promote skin-to-skin bonding pose unintended risks to the child.
  • Hospitals must create policies for close monitoring of newborns with the mother.
  • Patients and families should be educated on the risks and prevention strategies.

A tragic newborn death illustrates the patient safety risks posed by simply leaving an infant to sleep in the arms of its mother, risks that are increasing with the emphasis on more physical contact between the mother and child.

An Oregon woman is suing a nurse and Portland Adventist Medical Center, where her four-day-old son died. Monica Thompson filed an $8.6 million lawsuit against the hospital and the unnamed nurse, claiming they were at fault for her child’s death because the newborn was put in bed with her at night to breast-feed while she was unsupervised and medicated with painkillers and sleep aids. (See the story in this issue for more about the incident and the lawsuit.)

She was medicated with Ambien and Vicodin a few hours before a nurse walked into the room, gave her the baby, and left, according to the suit. Thompson said she fell asleep with the baby in her arms and woke up to find her son not breathing.

Her son suffered brain damage and was removed from life support after doctors said his comatose state was irreversible.

Although not a common incident, the injury or death of a newborn in the mother’s arms is a known risk and must be addressed, says Susan C. Wallace, MPH, CPHRM, patient safety analyst with the Pennsylvania Patient Safety Authority (PPSA) in Harrisburg.

In Pennsylvania alone, Wallace’s research found about 30 incidents per year in the several years she studied. Her analysis of reports submitted to the PPSA from July 2004 to 2013 revealed almost 300 incidents of family members dropping their newborns after falling asleep, newborns slipping out of family members’ arms to the floor, and newborns receiving bumps to their heads while being cared for by their families. More than 9% of the incidents resulted in serious patient harm. (Wallace’s full report on this safety risk is available online at: http://bit.ly/2gPZ7Zp.)

Most incidents (85.3%) occurred when the newborn was younger than four days old. Of those falls, 42.7% occurred on day one and 32.8% occurred on day two.

Hospitals must create policies and procedures to protect newborns from this risk, but that can be complicated by competing, and legitimate, efforts to provide more skin-to-skin contact between mother and child, more breast-feeding, and less time away from the child’s family. Breast-feeding also produces hormones that make both mother and child sleepy.

Newborn injuries and deaths in the mothers’ arms often occur during or after breast-feeding when the mother falls asleep, Wallace says. Mothers are excited to be with their new babies and underestimate how exhausted they are, she says. If the mother becomes groggy or falls asleep, the baby can smother against the mother’s skin, clothing, bedding, or a pillow. Entrapment also is possible, and the mother could drop the baby onto the floor.

Events of this type documented by the PPSA occurred in the early morning hours, and in one instance the nurse was rounding and found a baby turned blue in the mother’s arms 15 minutes after last checking on them.

“It’s important for hospitals to take an active role in informing them that, though these events are rare, they do happen. Ideally, it would be done in the doctor’s office before they go in labor, so it’s in their minds that this can occur,” she says. “The push for skin-to-skin contact and breast-feeding means they are holding their babies a lot more and a lot longer than they ever have before as hospitals try to follow these guidelines that encourage bonding.”

Hospitals Addressing the Risk

Hospitals should encourage mothers to be alert for the risk and call for a nurse or hand the child to the father or another family member, Wallace says. The baby’s bassinet often is in the room, but if the mother is sleepy or tired she may not be able to place the child there safely when that requires getting out of bed. Manufacturers are beginning to design neonatal beds with the bassinet attached to the side of the bed, and some bassinets can be positioned over the mother’s lap like a meal table. Both designs help reduce the risk to newborns, but do not eliminate the problem. (The PPSA offers several resources on patient education and statistics on newborn injuries, which can be found at: http://bit.ly/2eSJnI3.)

The five hospitals in the Portland area, including Portland Adventist Medical Center, have addressed the newborn risk through improved policies and procedures in recent years, says Linda Helsley, level II nursery clinical specialist at Mount Auburn Hospital in Cambridge, MA. She recently worked on newborn patient safety with five hospitals in the area.

“We eliminated all the PRN hypnotics from the postpartum order sets for exactly that reason. If they were going to give a hypnotic to a new mom, they wanted it to be a thoughtful, careful decision and put preventive measures in place if they were going to give those drugs,” Helsley says. “The number one advice to risk managers would be to look at the postpartum order sets and make sure you don’t have PRN hypnotics on there. Also, hypnotic use in younger women has become very common, with women coming in to have their babies and assuming they will continue their use of Ambien.”

The hospitals in the Portland area, and others addressing this risk, will provide sleeping aids during long labors but avoid them postpartum, Helsley says. Hospitals also should evaluate the mother postpartum to determine the risk of leaving the baby with her. Consider factors like the length and severity of the labor, the delivery, any medications, physical weakness, and emotional factors.

“If the mother is very tired or numb from an epidural, for instance, you want to have someone standing by the bed if she’s breast-feeding in the middle of the night,” Helsley says. “They may be more tired than they’ve ever experienced, and they’re also in a bed that is unfamiliar. A hospital bed often has them at a 45 degree angle, which changes how the mother and baby move and where the baby ends up if it slips from her arms.”

When the risk is high, the hospital can require that there be an awake, alert adult present to monitor the child. That can be the father or another family member, a friend, or hospital staff, Helsley says.

Hospitals that still have nurseries rather than the baby staying in the mother’s room most time of time, usually smaller hospitals, face the additional challenge of adequate communication between the nurses, Helsley says. When a nurse is caring for the mother and child in the same room, that nurse is more aware of the risk factors that may make it dangerous to leave the baby in the mother’s arms, she explains.

“If a nurse is in charge of six or eight babies, and another nurse is caring for the mother, the nursery nurse might bring the baby to the mother without any knowledge of the things that the other nurse knows,” Helsley says. “They have the added responsibility to communicate fully about the mother’s condition and any risk factors that are not apparent.”

Risk managers should watch for incidents involving newborns in their falls and unusual occurrences databases, Helsley says. Falls of just a few feet from a hospital bed can be serious or deadly to infants because they are top heavy and tend to land on their heads, leading to skull fractures, she notes.

“It is not uncommon for a parent not to tell anyone about a newborn fall, so it is possible that those incidents are underreported. Research has shown that to be the case, because they’ve just had this new baby and they’re horrified that they dropped it, and they’re afraid to tell anyone,” Helsley says.

Patients May Resist

Nurses have long battled the risks posed by leaving a newborn in the mother’s arms, says Connie Furrh, RN, a risk manager who has worked in neonatal care since 1970.

“This is not new. Moms always think they can handle it, and nurses have always tried to educate them that it can be dangerous. We always told them not to sleep with your baby in the bed,” Furrh says. “But you sometimes have to recognize that the mothers are the mothers and we’re just nurses, and it can be hard to say, ‘I’m taking your baby away whether you like it or not.’”

Nurses also are charged with so much education for new mothers — cord care, circumcision care, colic, basic safety issues — that the risk of smothering in her arms can get lost in all the rest, if they absorb much of anything in their exhaustion and medicated state. Posting illustrations of the risk and what it looks like when the baby slips from a sleeping mother’s arms can help.

Co-sleeping has been debated and researched for years, Furrh notes. There are definite benefits but certainly serious risks, as well. Even when the hospital has a policy prohibiting or limiting co-sleeping, the challenge for nurses is enforcing that policy when the parents disagree, she says.

Nurses often find it challenging to educate parents about the risk of co-sleeping and get them to comply with precautions.

“They’re only with us for 24 hours now, so they’re going to do what they want at home. But our answer is to just say, ‘Our rule is don’t do it here, and here is why,’” Furrh says. “In all things at the hospital, all we can do is say, ‘Here is what we think is best for you,’ but people don’t always abide by that. Our job is to try to teach them the best thing for their health and the health of their child, but ultimately they get to make the decision because they are the parents.”

Furrh notes that the nurse in question must be traumatized by the experience. Nurses caring for newborns are especially dedicated to their jobs and their patients, she says, and the accidental death would be devastating.

She also notes nurses typically are burdened with heavy workloads. It is unrealistic to expect them to sit with mothers as they nurse. Healthcare aides may be employed for that precaution, but hospitals don’t tend to hire a lot of staff to just sit and watch a patient, she notes. If there is no family member to help, waiting while the mother finishes nursing could mean neglecting other patients.

Although it is not clear what policies were in place at Portland Adventist Medical Center or exactly what the nurse in question did or didn’t do, Furrh says nurses can be placed in difficult situations when trying to do the right thing.

“Did the nurse try to take the baby but the mother groggily said, ‘No, you’re not taking my baby?’ Did she resist the nurse and didn’t remember it the next day?” Furrh asks. “What does the nurse do? Is it assault if you forcefully take the baby away from her?”

SOURCES