Considerations for the Neonate Delivered at Home

1. Considerations for the Neonate Delivered at Home Susan J Dulkerian, MD Director of Nurseries, Mercy Medical Center Fetus and Newborn Subcommitee Chair AAP, Maryland Chapter

2. State of Maryland Infant Mortality • Several years ago, rate was significantly higher than the national average. • Many state-wide initiatives have been made-> with resultant significant decrease in mortality and improved safety and quality of care is delivered to neonates throughout the state • Mortality rate at 6.7/1000 in 2010 & 2011 – lowest in recorded history of stats in MD

3. Neonatal Care in the Peripartum period • Care as outlined in the Guidelines of Perinatal Care, Sixth Edition • NRP expertise and equipment • Transition of Care of the acute infant • Newborn Screening • Bilirubin screening and follow-up • Follow up care

4. Neonatal Care • Care delivered to a neonate should be the same, independent of the delivery site. • Care should be as outlined in guidelines, and should take into consideration: mother’s history, the labor and delivery history, and the neonatal exam and course

5. Neonatal Transition and Resuscitation • Birth is usually a benign and natural event • 10% of all deliveries will require some assistance of the normal transition to exteruterine life • Neonatal Resuscitation Program (NRP) Guidelines

6. NRP • One person present at the delivery whose sole responsibility is to care for the infant, and who can perform neonatal resuscitation, including intubation • Appropriate neonatal equipment should be immediately available for all deliveries

7. Neonatal Transition and Resuscitation • Prior arrangements should be made between the midwife provider and the accepting facility/providers, in the event that transfer is necessary • Assure complete and accurate transition of care to accepting pediatric provider • Prior arrangements for transport, if needed

8. Immediate Neonatal Care • Assess for risk factors for hypoglycemia, screen if indicated. If persistent, transport should be arranged for ongoing monitoring and treatment • Cord blood type and Coombs should be sent in all RH negative moms, bilirubin level as clinically indicated • Consider evaluation of infants born to O+ moms • Intramuscular Vit K- studies show that oral vitamin K is not well absorbed

9. Newborn Screening • Metabolic screening- done at 24 hours after initiation of feeds- screens for inborn errors of metabolism which are life-threatening if missed; hypothyroidism, sickle cell disease • Hearing screening- every neonate should be screened for congenital hearing loss (intervention works!) • Congenital Cyanotic Heart Disease Screening (CCHD)

10. Congenital Cyanotic Heart Disease Screening (CCHD) • As of September 1, 2012 all neonates should be screened for CCHD at 24-48 hours • Those who do not pass screen will need further evaluation and an echocardiogram as soon as possible

11. Transition of Care • Follow up pediatric provider should receive a summary of infant’s history and neonatal course • Arrange for reevaluation within 24-48 hours by a pediatric provider • Follow up assessment for hyperbilirubinemia and level if clinically indicated