Step 7: Rooming-in

Mother and baby with nurseStep 7. I love step seven. Put 2 fingers up on one hand, and then take your other hand and wrap it around. That’s step 7—tuck families in together. Step 7 is probably the most practice-altering piece of Baby-Friendly for us. We have had some success, but in order to consistently live out step 7, we have more work to do. The answers on our self-appraisal are “no,” because while some of these elements may be available or even encouraged some of the time, they are not yet part of our routine practice.

Step 7.  Practice rooming-in—allow mothers and infants to remain together—24 hours a day.

7.1  Do mothers and babies stay together and/or start rooming–in immediately after birth? No

7.2  Do mothers who have had cesarean sections and/or other procedures (including those with general anesthesia) stay together with their babies and/or start rooming-in as soon as they are able to respond to their babies’ needs? No

7.3  Do mothers and infants remain together (rooming-in) 24 hours a day, except for a period of up to one hour for hospital procedures or if separation is medically indicated?  No

7.4  Do staff explore reasons and provide education to mothers who request their infants be cared for in the nursery? No

7.5  Are routine procedures conducted at the mother’s bedside whenever possible in order to avoid mother/baby separation?  No

Below are the concerns I hear about rooming-in. I think these are typical concerns that other Baby-Friendly hospitals have had to work through. In other words, we’re not dealing with anything unique, and we will figure out how to make this work, just like 134 U.S. hospitals that are already Baby-Friendly and the 373 U.S. hospitals working toward Baby-Friendly just like us. I’m throwing these out for everyone to discuss. Let’s find solutions!

Concern #1: Mom just had a cesarean and there are no family members in the room to help care for her and the baby. The mother can’t lift the baby out of the bed, and we’re afraid if we put the baby in mom’s arms, she will fall asleep.  (It seems like this would fall under 7.2 and may be a justified reason for taking the baby to the nursery.)

Concern #2: Baby is a “silent choker.” If I leave the baby with the sleeping family, no one will notice when his mouth or nose needs to be bulb syringed.

Concern #3: The baby is retracting (sign of breathing problems) and his coloring is even dusky at times. (This seems to clearly fall under 7.3 “or if separation is medically indicated.”)

Concern #4: The mom is exhausted, and I want to help her.

Concern #5: The mom requests for the baby to go to the nursery.

Concern #6: We don’t have enough nursing staff to do all admissions in the room when we are busy. (For those of you reading outside of Memorial, we have labor-delivery-recovery rooms, then patients are transferred to a separate unit for postpartum.)

Concern #7: Sometimes I do all the admission tasks in the room and then the mom asks me to take the baby to the nursery anyway.

Concern #8: If we don’t offer to take babies to the nursery, our customer satisfaction scores will suffer.

OK. There are the concerns I’ve heard. Are there others? Let’s get them out there and start moving toward solutions together!

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About blogtobabyfriendly

blogtobabyfriendly is written by Amy Murray, a Childbirth Unit nurse with a touch of earth muffin crunch. A childbirth educator and IBCLC, she's been a breastfeeding advocate all her adult life, believing that if our bodies make milk, it just makes good sense to feed it to our babies. blogtobabyfriendly is her hospital's journey to Baby-Friendly designation. Click to get email updates on new blog posts. Our desire is to learn, share, and learn more.
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24 Responses to Step 7: Rooming-in

  1. Anna-Marie Darden, RN says:

    I work in a facility that is going Baby Friendly as well. We practice rooming-in so it’s not a change for us. I know that making any kind of a change can be difficult. Rooming in is really great for breastfeeding and bonding for the family. I know lots of mothers might want a “break” from time to time, but if you let then know from admission time that baby will be in the room, they tend to be ok with it. Also, if you talk to them about the positives of it and make it a good thing, it tends to go over better. It’s really not an issue for us and it’s so much easier in the long run. Just hang in there…you can do it 🙂

    • Kelly Gomez, RN says:

      I love it!! I think it’s great you let them know from the start and talk about all the positives. I truly believe it’s how we present the idea of rooming-in that will be the change we want to make at Memorial. Thank you for the encouragement!

  2. melissa says:

    With my first child I had a hard time coming off of the anesthesia and took medicine that pretty much took me out for the count. I remember the nurse coming in one night with the my son to nurse and almost leaving again because I couldn’t wake up. I did have him sleep with the nurses because I was drugged and also to try to get some better sleep while recovering from surgery. I did the same thing with my daughter though I took her back later in the evening. I was suffering from a terrible chest cold when she was born so my goal was to try to get as much sleep as possible while I had some extra hands on deck. They were both with me all day. She has been sleeping in our room since we got home and we are just now getting her room ready for her to move to the crib (3 months!). I was very determined to nurse and I think if nursing had not gone as well as it did with both of my children I might have tried having them in the room 24/7. My situations prob. fall under the medical exceptions but also my personal preference.

  3. Our hospital became Baby-Friendly in 1998. We had a lot of our co-workers were concerned that mothers would not like it and that”Babies will die in the room”. We have never had that happen. We took baby steps. First we told all mothers in our classes about how rooming in would benefit them. Then we informed all families on admission that we will be caring for them both in the same room. They love being able to keep the baby with them. Of course there are mothers who want the baby out of the room, but we inform them that we do not staff a nursery. We take them out for some tests and procedures. Sometimes due to illness or other concerns a baby may need to move to the NICU. But I would say for the most part it becomes a very good way for new parents to prepare for home. We do show them how to comfort the baby with skin to skin care, We encourage family members to stay to learn how to help the baby and mother bond.

  4. Irit Librot says:

    Our birthing center is very small…6 LDRP’s. We have been Baby-Friendly since 1997. We have no nursery, just a tiny “treatment room”, so it makes it easy to accomplish rooming-in. When moms ask us to take the baby to give them a rest, its an opportunity to show them how they can
    rest with their babies. Side-lying and breastfeeding usually works like a charm to quiet those
    cluster feeders. Its pretty rare that we take a baby out to our nurse’s station to give mom a “break”. Sometimes the Dad takes the baby “for a walk” to give mom a rest. But if we are busy, we can’t sit there to watch the baby. I think it’s a culture that has to develop over time and education, and it will end up an expectation.
    As far as Cesareans, we are moving towards skin-to-skin in the OR, and recovery now occurs in mom’s room, so mom and baby never separate:) Our C/S moms are not usually gorked, and can respond to their babies well. They are encouraged to call us to assist them with the baby as needed if they can’t do it themselves.
    Good luck and stay with it…it will be well worth it.

    • Olivia says:

      After my c-section I was alone for a time with my baby and the nurse simply told me to call her if I needed help putting my baby back in the bassinet. Pretty easy solution.

  5. Julia Decker RNC, IBCLC says:

    I have heard that this is a major stumbling block for many hospitals. Our birthing center is even smaller than Irit (above) in that we have 4 LDRP’s. We have a very small nursery that we can use for sick babies or babies being circ’d., or for other treatments. We have also started doing hearing screens in mom’s room. It’s amazing how much easier with mom holding the baby or even breastfeeding! One department that had a major push-back was the lab but even they are feeling more comfortable doing “their thing”. One of the techs (who complained the most initially!) commented the other day that the baby did not cry as much when with mom! We do educate our families and most generally everyone really likes to have baby close. We are on our way to Baby-Friendly and are in the third “D” (Dissemination) Phase. Everyone is being encouraged to complete their competencies as we are through the “classroom” training! I just recently put together a PowerPoint presentation the nurses are now showing those moms who have chosen not to breastfeed, on safe formula preparation and feeding.

  6. Alisa S. Davis says:

    We becmae Baby Friendly last year. We have been rooming in for quite a few years. I tell the parents that they are on a steep learning curve when they have a baby and with rooming in we are just a call bell away when they have questions. Our patients are advised that we don’t have a nursery per se. I, as a mother of three, have never understood this “will you take my baby.” We get an occasional complaint from Mom’s who are “tired”. But there is so much medical evidence now that this is the best thing for baby that staff really can’t fight against it. Hang in there. It took us 10 years but was well worth it!
    Alisa S. Davis, RN, IBCLC
    Perinatal Nurse Educator
    Naval Hospital Jacksonville

  7. Diane Bibb says:

    We became Baby-Friendly in 2009 at Hannibal Regional Hospital. Rooming-In was an obstacle for our nurses more than our patients at first. The nurses had always “helped” the mothers rest by taking the baby to the nursery at night and they were concerned we were not helping the mother and parents would not like it. We spent months discussing how we could better help our moms and baby’s rest and brainstormed with nurses about how this could work. Ideas that came out of the discussions were: implementing nap time in the afternoon on the unit, clustering nursing care, developing tools for nurses to use to help parents learn soothing techniques in the middle of the night, placing a ribbon across the door when mom and baby are napping, and educating parents prenatally about the benefits of rooming-in. Now that we have been rooming-in 24/7 for several years no one can imagine going back to caring for moms and baby’s any other way.

  8. Carol McShane-Street, RN, IBCLC says:

    I am from a Baby-Friendly hospital and we have been designated for over 10 years. 24-hour rooming in was by far our biggest obstacle to overcome, but it can be done! It is a culture change, but in the end, you will be happier when your parents are happier and more confident in their ability to go home and take care of their baby – even at night! We do ongoing education for the staff and allow sessions to let us know what may be issues. We developed a room poster that tells why we support and encourage 24 hour rooming in.
    #1 The staff members have to truly believe that it is best for healthy mothers and babies to stay together. In order to make caring for couplets easier, we do all mother/baby care. The mothers are educated on admission about the advantages to keeping her baby with her and that 24 hour rooming in is a part of the care we provide. If the mother or baby is not stable enough to remain together, then it is documented in the medical record. Medical reasons for separation are accepted. However, by the way you have answered the questionaire from Baby-Friendly, it sounds like your babies are routinely separated from mother.
    #2 We have never had a complaint about offering rooming in. Over the years we have had some moms complain that they felt “pressured” to room in, but it is rare. If a mom asks to have the baby taken to the nursery, we explore the reasons for the request, and provide them with education on the advantages of keeping the baby with her. If she still wants nursery care, it is provided with the baby being returned for feedings. It is documented in the chart and that is key.
    #3 Everyone has to get past “mothering the mother” and start looking at the long-term breastfeeding relationship they are fostering with every new mother and baby. We are not doing mothers any favor by taking the baby to the nursery when fussy or because mom needs to sleep because feedings may be missed and mom’s milk supply will suffer. She needs to learn how to do night-time parenting in order to take the baby home and not be frustrated. From the time the baby is born we talk about newborn day-night mixup so they are prepared. We also do not have them stay together alone without help. We check on them frequently and show them how to settle the baby. We use skin to skin contact most of the time for settling. We also have swings, CDs with calming music, and white noise machines. If we are able to calm the baby in the nursery we are able to calm the baby in the mother’s room. Staff members need to really look inward to examine why they think it is necessary to separate mothers and babies.
    #3 Routine separation of mothers and babies or staff members offering to take the baby away from the mother is never acceptable. This has to be supported by all staff and management. If it is your unit policy and staff is not following policy, there has to be consequences. It is a part of our merit evaluation for the staff members to be supportive of the Baby-Friendly steps.
    #4 Staffing is often used for an excuse and maybe it is a true issue. However, I don’t think it takes any longer to give care to babies in the mothers’ rooms than it does in the nursery. In fact, it should take less time because you don’t have to transport the babies back and forth.
    #5 Encourage family involvement and unlimited visiting – family centered care. We have fold away beds for family members and if dad can’t stay (or is not involved) we encourage another family member to stay.
    To Melissa above: you cannot project your experience on other mothers. Everyone needs to have their own birth experience and we need to support them in getting breastfeeding off to a good start. It is not in the best interest of healthy mothers and babies to be separated. We have found that even for our formula feeding mothers, it is best if they stay together and learn night-time parenting. With short hospital stays, we have limited time to educate new mothers and caring for the baby provides a multitude of teaching moments.

    • Carol McShane-Street, RN, IBCLC says:

      By the way, we provide care in the same way you do – Labor, delivery and recovery in a birthing room and then transfer to a post-partum room. The nurse for L&D also cares for the mother and baby after delivery, so they all stay together. When mother is transferred, the baby goes with her to her room. It is a great system!
      Good luck to you and your families. You will be providing the best possible care when you accomplish this goal!
      Carol

      • Thanks Carol! I agree and also think Melissa’s comment is a good reminder that we need to consider each patient as an individual with unique needs. Rooming-in enhances breastfeeding success, bonding and confident parenting. Because some mothers have experiences like Melissa’s, where some nursery care may be the compassionate thing to do, doesn’t mean we can use such experiences as an excuse not to provide what is best for most families. Congratulations Melissa on your successful breastfeeding and home rooming-in for 3 months! The picture of you and me after your first delivery remains a cherished memento of my nursing career!

  9. Sarah mcKibben says:

    This is good stuff, but what about getting side-car cribs or co-sleepers? Your beds are too narrow AND have gaps so you can’t co-sleep even if you wanted to, and the bassinets are way too high and often positioned out of reach. Since I ended up with an epidural Ina 48-hour labor, I couldn’t walk to go pick up my baby, and I didn’t feel comfortable buzzing, plus I was petrified… I didn’t need mothering, I needed a pep talk. And to be allowed to bloody sleep for the last night I’d be able to for a year…..

  10. Sarah McKibben says:

    The last part of my comment means not that baby should exit but that mom shouldn’t be wakened unnecessarily. Now someone will say it’s the rules. But surely one could check in on mom when she’s awake and let her sleep if she’s sleeping. I don’t get why hospitals are so indifferent to the need for sleep. Surely there’s a better way.

    • Sarah that is a great idea! We’ve heard that at Baby-Friendly hospitals they ask the mom to put her call light on when she is awake feeding the baby. At that time the nurse goes in and takes mom’s and baby’s vitals and helps the mother in whatever way she needs. I love your comment about needing a pep talk too! I often think my role as a nurse/lactation consultant/mother/wife/friend is about 85% cheerleader. Kind words go a long way!

  11. Jenna B says:

    I am all for having the baby as much as the mother wants him/her, I always kept my kids all day and some of them at night. But, I don’t think it should be required to have them at night. My biggest concern with this is the night thing. My 3rd baby turned blue (twice) in the middle of the night (about 5 hrs after he was born.) Thankfully, he was in the nursery and the nurse was there to give him oxygen. I always think what a horrible outcome we would have had if I had kept him in the room with me that night. He was full term (40 wks) & prefectly healthy when he was born but still ended up in the NICU for 5 days.

  12. Sarah McK says:

    That would be brilliant — putting on light to notify and getting vitals done then. In fact, it would be a smart idea for more than just moms, but I leave that paradigm-transforming idea to others… As for being 85% cheerleader, you are absolutely right and I still thank YOU PERSONALLY in your role as lactation consultant at the free Monday clinic for promoting, salvaging, nurturing my breastfeeding relationship — which had a very rocky start due to aforementioned 48 hours of labor (and perhaps also my not holding/cuddling/doing skin-to-skin more in the first hours)… YOU were a big part of the reason that I ended up getting through the first very very painful 6 weeks (with a barracuda latch from a very very hungry baby), establishing a good milk supply (during which, as you may recall, my son gained 2 ounces day — as I know since I visited the free clinic for weigh-ins EVERY SINGLE WEEK for ages and ages)…and eventually nursed my son until he was 2.5. I had ZERO sick visits the first YEAR of his life (and just one little transient norovirus) and he’s remained remarkably healthy and also a good eater…. Speaking of lactation consultants, I do think it’s important that they be CALM and assured. Some are much better than others, and the good ones are worth their weight in gold. I just wish insurance companies saw it that way and made it easier to consult and get reimbursed, but they don’t. And it’s so short-sighted, since a healthy nursing relationship can yield marvelous health benefits (and savings) for all.

    • Thanks Sarah! We also have my friend Karen to thank for the breastfeeding support group/clinic. She recognized 7 years ago that even though we weren’t ready to pursue Baby-Friendly designation, having free, out patient support was something we could begin. There are two sides to every coin, and I understand from the medical standpoint why vitals, daily weights, labs, etc. have to be performed at certain times. However, it is time for us to stop saying “we can’t” and figure out ways we can. The healthcare world is changing. I’m excited to be changing right along with it!

  13. Mary Foley RN IBCLC says:

    Congrats to you all on tackling Step 7…also our hardest step. The staff at the bedside, especially at night are to be commended for their willingness to ask the tough questions, and learn a new way of caring for moms and babies…it’s not easy! I remind my staff that Baby Friendly expects rooming-in to be the “standard,” which is reflected by at least 80% compliance. There is room for exceptions and nobody wants any nurse to leave a baby in an unsafe situation. But exceptions shouldn’t be happening more than 20% of the time…then they wouldn’t be “exceptions.” 🙂 So I ask the staff to look at their own patient mix. Are they able to help at least 8 out of 10 of their mother/baby pairs to stay together 24/7? Great! They are practicing rooming-in.

  14. Dr Mommy says:

    I think most of our barriers to rooming in have more to do with our provider culture than it does with the expectations of moms. As a doctor who cares for babies and moms I have noticed things like how empty the nursery is in the middle of the day and how often moms ask me when I am doing morning rounds if someone could bring their baby back to them. As a mother myself I remember wondering how long it takes to bathe and assess a newborn when over 2 hours passed and my baby still was not brought back to me. If I had known my baby was just sitting under a warmer I would have asked to hold my baby skin to skin instead, but I assumed the nurses were still doing something important out there and I did not want to interfere. I think a lot of moms accept our processes because they don’t want to bother us and they assume we have a system designed with their best interests in mind. If we change our nursing and doctoring culture so that it is normal to keep the babies and moms together we may be surprised at how easily our patients accept this as normal and how little effort is required to convince moms to keep their babies with them. We already allow our patients to eat when they are hungery and not according to the hospital schedule, why not let moms determine when they need help with the baby and stop offering to remove the baby from the room which implies that seperation is normal and expected.

  15. Tracy says:

    When I had my baby 2 1/2 years ago at Memorial I was told in all of the classes that rooming in was encouraged and it was rare for babies to be in the nursery. At first this made me nervous, but eventually I grew to love the idea. I found though, that while I was actually in the hospital the nurses offered to take the baby to give me some rest a lot more than I expected (or needed). I think rooming in is extremely valuable for new mothers so that the first night(s) at home without nurse support aren’t so overwhelming. I can’t imagine going home for that first night without having the experience of rooming in at the hospital.
    I also would have loved for all procedures (as possible) to be done in the room with me. They took my little one for her bath and check ups so soon after delivery that I was sad and worried about her. I would have loved if they could have done all of that in the room so that I could be there to experience it all with my baby.
    And I totally agree that the constant interruptions while in the hospital were very difficult to manage. It felt like every time I was finally getting some rest someone was coming in to check on us. Turning on a light to indicate that we were awake and ready to be bothered is a wonderful idea. I’m sure you can’t avoid all interruptions that way, but any help is better than none.
    One last thing, the bassinets are very high (and cosleeping in a hospital bed is not a very safe option) which makes the baby difficult to access while in the bed. My epidural seemed to take forever to wear off so I couldn’t get out of bed to get to my baby when she needed me. My husband needed to leave for a few hours and it was frustrating to have to call the nurse every time I needed/wanted to hold my baby. If the bassinets were lower and more accessible from the mother’s bed I think it would help with some of the concerns of #1 (although c-sections might be a different story).

    • Thank-you Tracy for sharing. I’m sorry there was a disconnect between what was said in classes and what actually happened. We are working harder on working together!
      After Sarah’s comment, I did search for co-side sleepers for hospital beds. I didn’t have any luck, but will keep looking. Just think, by the time you have your next baby at Memorial, rooming-in really will be our norm!

  16. Randi says:

    I love the idea of “natural csection” I had went into the Memorial thinking that I would have a natural childbirth. As you know nothing happens as planned and after 36 hours of labor I needed to have a c-section. I had a hard time after delivery as I was not able to see my daughter right away or able to watch my husband cut her umbilical cord as it was all done at the foot of my bed ( it would even be better if the babys area was in a location that the mother could see everything that is happening). All I have to see is pictures. I’m very thankful that I have a healthy daughter. I think that it would have been great seeing my daughter be born and then being able to do STS. When I was watching the natural section video I cried becuase I would have loved to have been given that opportunity. I agree with having the hospital bassinets lowered as I had to have my husband get my daughter everytime since my epidural was still in my system. I do feel that my nursing staff did a great job with not having my daughter gone for too long ( I was able to nurse and they did not have to supplement). I think that this is a great step for memorial to go in and am very excited to see this evolve.

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