In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding

Abstract

In-hospital neonatal falls are increasingly recognized as a postpartum safety risk, with maternal fatigue contributing to these events. Recommendations to support rooming-in may increase success with breastfeeding; however, this practice may also be associated with maternal fatigue. We report a cluster of in-hospital neonatal falls associated with a hospital program to improve breastfeeding, which included rooming-in practices. Metrics related to breastfeeding were prospectively collected by chart audit or patient survey while ongoing efforts to improve breastfeeding occurred (September 2015–August 2017). Falls were identified through the hospital adverse event reporting system from January 2011 to February 2018. Medical records were reviewed to determine factors associated with the falls, including time of event, pain medication administration, hours of life at fall, method of delivery, or other notable factors that may have contributed to the fall event. Three fall events occurred within 1 year of commencing improvement efforts as process and outcome metrics associated with breastfeeding improved. All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am. Falls occurred from 38.0 to 75.7 hours after birth. No sedating pain medications were administered within 4 hours of any event. In 2 of 3 cases, mothers experienced notable ongoing social stressors. Rooming-in was the most significant change involved in our health care delivery during the programmatic effort to improve breastfeeding. Monitoring for in-hospital neonatal falls may be needed during projects aimed at improving breastfeeding, particularly if rooming-in practices are involved.

Falls of newborn infants in a New Zealand hospital: A case series

“…It is important to support and encourage the establishment of breastfeeding in the neonatal period, including rooming‐in and taking babies to bed for feeding. However, in one study the introduction of rooming‐in resulted in more baby falls while breastfeeding at night 8 . Maternal tiredness at night and after birthing is to be expected especially if the mother is on sedating analgesia or has other contributory risk to excessive sleepiness, for example obstructive sleep apnoea which is reported to be prevalent in pregnant people with obese body size and therefore may have been a potential contributory factor in this study 9 .…”

The Perceived Knowledge of Fall Prevention in Nurses Working in Acute Care Hospitals in China and the United States

“…One group of researchers associated falls with maternal fatigue, rooming in, and encouraging breastfeeding as potential risk factors. 25 The Joint Commission in an advisory on safety called “Preventing Newborn Falls and Drops” identified cesarean birth, use of pain medication, second or third postpartum night (especially around midnight to early morning hours), and breastfeeding as potential risk factors. 26 They recommended strategies, such as developing an assessment tool, education, rounding, promoting maternal rest, and developing signage as safety actions to consider.…”

Gestão de segurança quanto à quedas de recém-nascidos hospitalizados: uma revisão integrativa / Safety management of hospitalized newborn falls: an integrative review

“…Para que o alojamento conjunto seja bem sucedido e o risco de queda seja reduzido, a díade mãe-bebê em risco de queda acidental no hospital deve ser submetida a vigilância adequada, o que requer uma extensa colaboração da equipe interdisciplinar, seja Brazilian Journal of Development, Curitiba, v.7, n.6, p. 57943-57955 jun. 2021 minimizando as interrupções do sono materno, considerando o cansaço existente no período pós-parto, e também nas orientações que visem diminuir as situações de risco de quedas, conforme apontado nos estudos dessa revisão (HUGHES DRISCOLL; PEREIRA; LICHENSTEIN, 2019;MINER, 2019).…”