Newborn Transition Care Guideline

Updated in December 2024, this care process model guides the University of Utah Hospital’s postpartum care team on the most appropriate level of care for term and late preterm newborns directly after delivery. When medically appropriate, the preferred location for the newborn to transition is on the mother’s chest. Nonetheless, certain risk factors or concerning clinical findings should prompt the team to take the newborn either to the Well-Baby Nursery (WBN) Transition Area or to the Newborn Intensive Care Unit (NICU) for additional monitoring, support, and intervention. The updated guideline includes simpler criteria for when to consult the NICU for possible hypoxic-ischemic encephalopathy (HIE) evaluation and more nuanced ways to obtain respiratory therapy support and escalation of care for distressed newborns in the WBN Transition area.

Key Points

1. Highest-risk infants go directly to NICU after delivery: prematurity <35 weeks, birth weight <1800 grams, receiving chest compressions, or prolonged continuous positive airway pressure (CPAP) and concerning respiratory status (e.g., a Transition Respiratory Score (TRS) of >=4 at 10 minutes of life despite CPAP trial).

2. Moderate-risk infants go to the WBN Transition Area after delivery: maternal intrauterine infection (“Triple I,” formerly referred to as chorioamnionitis), maternal HIV, infant having received any CPAP or positive pressure ventilation (PPV) or develops any respiratory distress or hypoglycemia (who do not meet additional criteria for NICU care) should transfer to the WBN Transition Area for monitoring to determine appropriate next level of care. (e.g., NICU for stable, healthy infants). After initial observation time in the transition area, e.g., 4-6 hours, stable infants with stable vitals and no ongoing need for interventions may return to paired care on Labor and Delivery or with the parent in the WBN. Unstable infants may transfer to the NICU for escalating needs or to the Intermediate Care Nursery (ICN) for ongoing monitoring and moderate supports.

3. Concern for possible HIE: the WBN attending physician will discuss SARNAT scoring with the NICU by 1-2 hours of life for all infants with either of these risk factors:

• Maternal cord gas pH <= 7.15, or
• Base excess < = -10 (aka base deficit >= 10)

The WBN attending will provide the NICU with pertinent information, including perinatal events, APGAR scores at 10 minutes, PPV use, and the infant’s current neurological status, to decide which babies the NICU will examine.

4. Respiratory distress escalation of care in the WBN Transition area:  Use paging groups, “CPAP Transition Assist” or “Baby Transfer NBICU,” to obtain the indicated level of additional support needed in the Transition area.

• CPAP Transition Assist accesses a Respiratory Therapist (RT) to assist with a brief trial of CPAP. The RT is not expected to help make clinical decisions about whether the baby needs NICU-level care.
• Baby Transfer NBICU pages notify the NICU Registered Nurse (RN) and RT about babies with significant respiratory distress needing to transfer from the Transition area to the NICU.  The WBN and NICU attendings also need to discuss patient handoff.

5. After initial stabilization and reassessment, NICU infants with moderate care needs may transfer from the NICU to ICN or WBN. This requires discussion between the NICU and the WBN/ICN attending and includes the following newborns:

• NICU to ICN: late preterm and term infants with a birth weight >=1800 grams and are comfortable on low levels of oxygen by nasal cannula with <=0.5 LPM and 30% FiO2 and stable glucoses with or without D10.
• NICU to WBN for paired care with parent: stable infants >=35 0/7 weeks without the need for ongoing monitoring and support. This means no feeding tubes, D10 drips, O2 use, or continuous monitoring. Phototherapy and antibiotics through peripheral IV can be done in the parent’s room.

6. When the pediatric resident is actively assisting with CPAP or another transition issue, the backup plan for deliveries will be for the NNP to attend. This usually pertains to night staffing due to the limited number of pediatric residents.

Newborn Transition Care Guideline

Article History

This article was first published on the Medical Home Portal and updated before publication on TRiP. The Medical Home Portal, retired in July 2024, provided diagnosis and management information for pediatric conditions, guidance for immediate steps after a positive newborn screen result, and in-depth family education to improve outcomes for children with complex medical care needs. The full archive can be found at the Medical Home Portal Archive. 

Topical Reviews in Pediatrics (TRIP) includes archival and updated content from the Medical Home Portal and features new, contemporary topics in pediatrics.  

• 2023 first edition: Julie Shakib, DO, MS, MPH^A; Bhanu Muniyappa, MD^A; Belinda Chan, MD^A; Allison Judkins, MD^A; Jennifer Goldman, MD^R, MRP, FAAP^R; Elizabeth R Smith, MD^R; Meghan M. O’Connor, MD^R; Kimberly Stowers, MD^R; Jose Morales Moreno, MD^R; Christina Thuet, MD, IBCLC, FAAP^R

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer