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

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

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

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

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

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

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

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

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)

As of September 1, 2012 all neonates should be screened for CCHD at hours Those who do not pass screen will need further evaluation and an echocardiogram as soon as possible

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