Guidelines for management of newborn hyperbilirubinemia have existed in Russia for many years. We sought to determine the degree to which management of hyperbilirubinemia in Russia meets three existing clinical protocols. We performed a cross-sectional chart review in a government-run, academic hospital in an urban setting in Moscow, Russia. Subjects were admitted to Level II nursery at Hospital No.13, were not transferred to a Level III nursery, did not die during hospitalization, and had at least one pairing of total serum bilirubin (TSB) and clinical evaluation of jaundice. We measured physician adherence to three available guidelines based upon TSB levels at which phototherapy and exchange transfusions were performed. We identified 594 infants and 1,924 pairings. Despite availability of TSB to inform decision-making, physicians did not follow the protocols. Under Russian and U.S. guidelines, physicians often failed to start phototherapy, started phototherapy unnecessarily, and missed recommended exchange transfusions. Despite a resource-poor setting, guideline adherence in Russia was remarkably similar to that of U.S. physicians. The data illustrate the challenge of overcoming physician behavior to standardize practice, and raise questions about the presumed higher quality of care in a more developed medical system. A new framework for guideline implementation is needed, and many of the necessary tools already exist.