North Colorado Midwifery provides total care of both mother and baby! I strive for total care to minimize interrupting the postpartum time, also known as the BabyMoon. I want families to enjoy this time and to not be running around to multiple health care visits. During postpartum visits, I keep track of the mom’s postpartum recovery, including help with lactation and, therefore, keep track of the baby in terms of weight gain, growth, development, all while looking for any signs of problems. If there is a problem with baby, I am happy to refer to medical care for evaluation, just as I do with mom during pregnancy and birth.
There has been lots of talk, and maybe some misunderstandings about midwives and newborn care. Most out-of-hospital midwives do keep track of the newborn and refer if the baby needs medical attention. I decided to look up the standard care guidelines for healthy term newborns and compare them to what I do after a birth at home. The information below is from the American Academy of Family Physicians website (http://www.aafp.org/afp/2004/0815/p777.html)
First, How Newborn Care Works in My Practice:
We have a birth and do an initial assessment of baby, including the apgar score and assessing for transition from fetal circulation to newborn circulation and breathing. This is done the first 5 minutes after birth, but doesn’t stop there. Then we are sure that baby is kept dry, minimize disruptions for mom and baby contact, while we go about the business of keeping track of the third stage of birth for mom. Once the placenta is delivered and mom and baby are stable, we give the family some nice and quiet bonding time while we clean up and take a breather ourselves (me and the rest of the birth team.)
When we are ready, usually about an hour or so later, we work on getting mom up for a shower if she chooses and do the newborn exam. First we cut the cord (yes, we waited this long), then we do weight and measurements. Keeping baby warm, we do a thorough assessment of the baby right there with the family present and participating if they so choose. Once everyone is tucked back into bed, the birth team leaves after giving instructions (again) for when to call us back if needed.
A return visit is usually done the next day, then again about day 3 for the newborn screen and a weight. Then I like to return again about day 5 or 6 for another weight to be sure it is heading in the right direction and to make some corrections in breastfeeding management if needed. I will return again in a couple of days if needed or wait until about 10 days to 2 weeks for another weight check and the second newborn screen. All the while doing assessment of the baby’s feeding and sleeping patterns, jaundice levels, and anything else that might be going on.
Comparison to the American Academy of Family Physicians Recommendations
Below is a list of bullet points from the AAFP website and I will insert my comments in bold:
The AAP recommends that the following minimal criteria be met before any newborn discharge. It is unlikely that fulfillment of these criteria and conditions can be accomplished in less than 48 hours. If discharge is considered before 48 hours, it should be limited to infants who are of singleton birth between 38 and 42 weeks’ gestation, who are of birth weight appropriate for gestational age, and who meet other discharge criteria as follows:
- The antepartum, intrapartum, and postpartum courses for mother and infant are uncomplicated. Yes, that is how we do it at home.
- Delivery is vaginal. Yes, again!
- The infant’s vital signs are documented as being within normal ranges and stable for the last 12 hours preceding discharge, including a respiratory rate below 60 per minute, a heart rate of 100 to 160 beats per minute, and axillary temperature of 36.5°C to 37.4°C (97.7°F to 99.3°F), measured properly in an open crib with appropriate clothing. We check for this before leaving the home, and again at the return visit the next day. We are also visiting a day or so after that and giving instructions to the parents to watch for these signs.
- The infant has urinated and passed at least one stool spontaneously. We are to note this within the first 24 hours. We will accept the parent’s report.
- The infant has completed at least two successful feedings, with documentation that the infant is able to coordinate sucking, swallowing, and breathing while feeding. We almost always get this done right after birth, before we leave the home, and we verify it has happened again the next day. If we have trouble, we are there to monitor baby’s behavior and will refer if baby can’t nurse at all.
- Physical examination reveals no abnormalities that require continued hospitalization. This is a given. If we have abnormalities, we refer to a physician or take baby to the hospital.
- There is no evidence of excessive bleeding at the circumcision site for at least two hours. If parent’s choose to circumcise, they usually wait a few days and get instructions from their physician.
- The clinical significance of jaundice, if present before discharge, has been determined, and appropriate management and/or follow-up plans have been put in place. We monitor for this and refer when needed.
- The mother’s knowledge, ability, and confidence to provide adequate care for her infant are documented by the fact that she has received training and demonstrated competency regarding the following: (1) breastfeeding or bottle feeding (the breastfeeding mother and infant should be assessed by trained staff regarding breastfeeding position, latch-on, and adequacy of swallowing); (2) appropriate urination and defecation frequency for the infant; (3) cord, skin, and genital care for the infant; (4) ability to recognize signs of illness and common infant problems, particularly jaundice; and (5) proper infant safety (e.g., proper use of a car safety seat, supine positioning for sleeping). We spend so much time with our moms and families, that this is exactly what we DO!
- Family members or other support persons, including health care professionals such as the physician or his or her designees, who are familiar with newborn care and knowledgeable about lactation and the recognition of jaundice and dehydration are available to the mother and her infant after discharge. Got this one covered. Do moms get as much attention from the conventional hospital care as they do from midwives who do care in the homes for at least the first week???
- The following maternal and infant blood test results are available and have been reviewed, including: (1) maternal syphilis and hepatitis B surface antigen status; (2) cord or infant blood-type and direct Coombs’ test results, as clinically indicated; and (3) screening tests performed in accordance with state regulations, including screening for human immunodeficiency virus infection. Got this covered too. We do labwork for mom during pregnancy. We do cord blood typing when indicated if mom is Rh negative, we do the newborn screen. We do offer HIV testing to mom during pregnancy.
- Initial hepatitis B vaccine is administered as indicated by the infant’s risk status and according to the current immunization schedule. Here is one we cannot do. We can refer to someone who can if the parents so desire.
- Hearing screening has been completed per hospital protocol and state regulations. Some of us in Colorado have access to hearing screening equipment or we can refer out for it.
- Family, environmental, and social risk factors have been assessed. These risk factors may include but are not limited to the following: (1) untreated parental substance abuse or positive urine toxicology results in the mother or newborn; (2) history of child abuse or neglect; (3) mental illness in a parent who is in the home; (4) lack of social support, particularly for single, first-time mothers; (5) no fixed home; (6) history of untreated domestic violence, particularly during this pregnancy; and (7) adolescent mother, particularly if other conditions above apply. When these or other risk factors are identified, discharge should be delayed until they are resolved or a plan to safeguard the infant is in place. We already have this covered during prenatal care. If anything, we know our clients much better than hospital personnel do so we don’t have to assess this post birth.
- Barriers to adequate follow-up care for the newborn such as lack of transportation to medical care services, lack of easy access to telephone communication, and non–English-speaking parents have been assessed and, wherever possible, assistance has been given the family to make suitable arrangements to address them. We will help if a problem occurs in accessing medical care. Other than that, we come to the family immediately postpartum.
- A physician-directed source of continuing medical care for the mother and the infant is identified. For newborns discharged fewer than 48 hours after delivery, a definitive appointment has been made for the infant to be examined within 48 hours of discharge. It is essential that all infants having a short hospital stay be examined by experienced health care professionals. If this cannot be ensured, discharge should be deferred until a mechanism for follow-up evaluation is identified. The follow-up visit can take place in a home or clinic setting as long as the health care professionals examining the infant are competent in newborn assessment and the results of the follow-up visit are reported to the infant’s physician or his or her designees on the day of the visit. I think we got this covered!
- The purpose of the follow-up visit is to: Obtain the infant’s weight; assess the infant’s general health, hydration, and degree of jaundice; identify any new problems; review feeding pattern and technique, including observation of breastfeeding for adequacy of position, latch-on, and swallowing; and obtain historical evidence of adequate urination and defecation patterns for the infant. Yes, we got it.
- Assess quality of mother-infant interaction and details of infant behavior. Can’t help but notice.
- Reinforce maternal or family education in infant care, particularly regarding infant feeding. This is begun before birth.
- Review the outstanding results of laboratory tests performed before discharge. Sure, if applicable.
- Perform screening tests in accordance with state regulations and other tests that are clinically indicated, such as serum bilirubin. We don’t often test for jaundice, but can if needed, or more importantly, we will refer out if jaundice seems extreme.
- Verify the plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screenings. Yes, that is what we do postpartum. After the visit at two weeks, I generally do one at 4 weeks and again at 6 weeks. Of course, more often if indicated and may still do these at a client’s home. I hate making mom take her newborn out and disrupting the peace.
- The follow-up visit should be considered an independent service to be reimbursed as a separate package and not as part of a global fee for maternity-newborn labor and delivery services. Ok, this is insurance jargon. Most midwives just charge a “package” fee and these visits are included in that fee and are not add-ons.