Background: The literature describes a newborn fall as a newborn being dropped from the arms of an adult falling asleep (67%), a fall during repositioning or transfer (22%), or a fall in conjunction with another person falling or tripping (11%).  Currently, the prevalence of in-hospital newborn falls is 1.6-4.14 falls/10,000 live births.  Our facility delivers approximately 3200 babies/year, and the rate of newborn falls in one 13 month period was 11.53 falls/10,000 live births: profoundly higher than what recent studies have found. The reasons for this higher rate have been unclear.

Case: During one 13 month period, 4 infant falls occurred.  Each happened on the Couplet Care unit between midnight and 0900.  The involved patients were all recovering from cesarean sections following prolonged labor.  Of the infants that fell, three were in bed with their mothers, the fourth involved the father.

In the three cases involving the mother, all were holding their newborn, fell asleep, and were awakened by their crying newborn on the floor.  One mother was breastfeeding, two were holding their newborn. In the fourth case, the father placed the newborn on the couch to change her diaper, turned for supplies and when he turned back, his daughter was on the floor.  In all cases, a support person was present but asleep at the time of the fall. 

The increase in newborn falls alarmed both leadership and staff.  Each case was carefully reviewed by a multidisciplinary team and the literature reviewed.  Possible contributing factors for the increase in newborn falls included increased emphasis on “rooming-in”, breastfeeding, and “skin-to-skin”; new beds on the unit which had large side-rail gaps at the elbow level; and deficits in staff awareness and patient education regarding infant fall prevention.

Multiple interventions were instituted:  Intense staff/parent education was initiated first, with parent education given in a “dosing” fashion, starting in Childbirth Education, then the Labor and Delivery, and Couplet Care units.  An “Eyes on Baby” component was added to hourly rounding.  Co-sleeping danger signage was placed in every room and the hospital beds changed to an older model with smaller side-rail gaps. 

Conclusion: It has been six months since implementation of the education and safety initiatives and we have had no further newborn falls.  Further research is required to identify additional causes of newborn falls and specific interventions developed and implemented.

Keywords: newborn, falls, co-sleeping, breastfeeding, skin-to-skin, safety