Facilitating discharge home following a normal term birth

A joint statement with the Society of Obstetricians and Gynaecologists of Canada 

Fetus and Newborn Committee, Canadian Paediatric Society (CPS) 
Maternal Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada (SOGC) 
Clinical Practice Obstetrics Committee, Society of Obstetricians and Gynaecologists of Canada (SOGC)

Approved by the CPS Board of Directors in 1996
 Paediatr Child Health 1996;1(2):165-8
Reference No. FN96-02

Revision in progress February 2009

Parent handout: Going home after the baby is born

Index of position statements from the Fetus and Newborn Committee

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Contents

Over the past two decades there has been a trend towards shorter hospital stays for maternal/newborn care. This occurred partially because of a need to curtail hospital costs and has been parallelled by shortened hospital stays for other patients. Discharge of the mother and baby from hospital within 48 h after birth began, first, as a consumer initiative and, subsequently, as an initiative of health care providers (primarily hospitals and insurance agencies). Mothers electing early discharge were more likely to be multiparous, interested in rooming in, rely more on themselves than others and to have learned about early discharge from printed information rather than from clinic staff1. Early discharge with home follow-up has been reported as a safe and effective use of health care resources2-7 and may offer psychological benefits to families8,9. Although short maternal/newborn hospital stays are common in many Canadian centres, published research provides little knowledge of the consequences for large populations10. In the United States, the American Academy of Pediatrics has published guidelines11 and is trying to facilitate legislation to require insurance companies to pay for care of mother and baby for at least 48 h after a vaginal birth and 96 h after a caesarean birth12. The purpose of this statement is to provide guidelines for physicians and other health care personnel to influence policy and practice related to discharge of healthy term babies and mothers from hospital and subsequent follow-up in the community.

Babies undergoing a normal 6 h postnatal transition are far less likely to have problems requiring hospitalization in the first three days of life than those who have an abnormal transition period4. The importance of individualized assessment in preparation for potential early discharge has been emphasized5. Women who are discharged "involuntarily" are more likely to be dissatisfied and have more problems than women discharged voluntarily13. This importance of choice related to childbirth has been addressed in other aspects of obstetrical care14.

After early discharge following a normal term birth, women are less likely to have problems requiring readmission to hospital (up to 1.8%, primarily for infection) than babies whose most prevalent reason for rehospitalization is neonatal jaundice (up to 10.9% [2], more commonly 2% to 3% [15]). Recent Canadian data indicate that a reduction in hospital stay after delivery from 4.5 to 2.7 days without community follow-up is associated with increased readmission to hospital, especially for hyperbilirubinemia and dehydration, after which at least two infant deaths occurred16. Establishing neonatal feeding could decrease the need for readmission of the baby, since inadequate breast milk intake is associated with increased neonatal jaundice17. Education and support must be provided to breast-feeding mothers. Successful early discharge programs have strong out-patient programs with community support15,18-22. Models of home follow-up have been described, including details of home assessments for the mother and baby22. In keeping with the principle of family-centred care23 and the ongoing facilitation of breast-feeding, it is important that babies and mothers remain together if one or the other needs readmission to hospital. Hospitals should ensure that their admission policies facilitate readmission of babies for at least the first seven days of life. This may require the development of hostel facilities for mothers whose babies are hospitalized.

In a study by Norr et al22, low income mothers discharged with their infants 24 to 47 h after birth showed no increased maternal or infant morbidity within 15 days after birth compared with previous patients who stayed in hospital 48 to 72 h after birth. Not surprisingly, mothers discharged without their babies had more concerns and less satisfaction. Mothers electing early discharge (24 to 48 h after delivery) are reported to show better postpartum adjustment than mothers who stayed in hospital for five to seven days24.

Despite the increasing prevalence of early discharge programs, controlled studies are relatively few. (Studies of early discharge of low birth-weight babies are not relevant to these guidelines.) Waldenström25 reported a randomly allocated study of discharge 24 to 48 h after birth with subsequent midwifery visits compared with traditional hospital stays (six days after delivery). Although the study may be biased because patients had to desire early discharge to enter the study, parents had a more positive experience with early discharge. They also rated this more highly than parents who did not enter the study and had traditional hospital care. A separate report indicated no difference in infant morbidity and prescribed medications in the first six months after birth between early discharge and traditional hospital care26. A similar study by Carty and Bradley27 showed that discharge of mothers and babies between 12 and 48 h after birth was associated with increased maternal satisfaction and breast-feeding without supplementation. While no differences in maternal or infant morbidity were seen, it was noted that the sample size was too small to detect significant differences in outcome. The need for further research has been documented10 and trials with larger numbers to address this issue are underway.

Discharge of healthy mothers and term babies before 48 h after birth (often within 24 h of birth) is a reality in many areas. Common components of most successful programs include the following:

Further research is required into support for the mother and baby in the home environment and to validate these (or other) discharge guidelines. It is the collective responsibility of physicians and other health care personnel, including administrators and funding agencies, to ensure early discharge after birth is implemented in a safe and effective manner.

Recommendations

  1. Care for mothers and babies should be individualized and family-centred. With many uncomplicated births, a stay of 12 to 48 h is adequate, provided the mother and baby are well, the mother can care for her baby and there is community nursing follow-up in the home. In the absence of these requirements, mothers should have the choice to stay in hospital with their baby for a minimum of 48 h after a normal vaginal birth. Women with complicated deliveries, including caesarean section, may require a longer hospital stay.
  2. With discharge from hospital before 48 h after birth, the guidelines in Table 1#1 should be followed. Individual hospitals may identify more specific criteria according to the needs of their populations and regions.
  3. When discharge occurs before 48 h after birth, this must be part of a program that ensures appropriate ongoing assessment of the mother and baby. This evaluation should be carried out by a physician or other qualified professional with training and experience in maternal/infant care. A personal assessment in the home is preferred for all mothers and babies. Relying on newly delivered mothers to travel to a clinic or office may result in many families being inadequately followed due to lack of compliance. This visit is not intended to replace a complete evaluation by a physician, but should focus on those aspects that require early intervention (eg, feeding problems, jaundice, signs of infection, etc). Programs should ensure availability of assessment, including on weekends, to:
  4. Preparation for discharge should be considered part of the normal antenatal education of all expectant mothers (and families), including information on infant feeding and detection of neonatal problems such as dehydration and jaundice. This should be reinforced during the short hospital stay.
  5. Hospitals with early discharge programs should work with community health agencies to audit outcome for mothers and babies to ensure that guidelines for early discharge are appropriate and being effectively used.
  6. When readmission of the baby to hospital is required within seven days after birth, the baby should be admitted to the hospital of birth with accommodation for the mother to maintain maternal/child dyad. When readmission of the mother is required, there should be opportunity for the newborn baby to be with her, if appropriate.


TABLE 1: Criteria for discharge less than 48 h after birth
Maternal Newborn
PURPOSE: To ensure postpartum mothers are safely discharged following the birth of their baby, they should meet basic criteria and have appropriate arrangements for ongoing care. Prior to discharge, the following criteria should be met. PURPOSE: To ensure newborn infants are safely discharged, they should meet basic criteria and have appropriate arrangements for ongoing care. The baby should be healthy in the clinical judgment of the physician, and the mother should have demonstrated a reasonable ability to care for the child.
  • Vaginal delivery
  • Care for the perineum will be ensured
  • No intrapartum or postpartum complications that require ongoing medical treatment or observation*
  • Mother is mobile with adequate pain control
  • Bladder and bowel functions are adequate
  • Receipt of Rh immune globulin and/or rubella vaccine, if eligible
  • Demonstrated ability to feed the baby properly; if breast-feeding, the baby has achieved adequate "latch"
  • Advice regarding contraception is provided
  • Physician who will provide ongoing care is identified and, where necessary, notified
  • Family is accessible for follow up and the mother understands necessity for, and is aware of the timing for, any health checks for baby or herself
  • If home environment (safety, shelter, support, communication) is not adequate, measures have been taken to provide help (e.g., homemaking help, social services)
  • Mother is aware of, understands, and will be able to access community and hospital support resources



* Mothers should NOT be discharged until stable, if they have had:

  • significant postpartum hemorrhage or ongoing bleeding greater than normal;
  • temperature of 38C (taken on two occasions at least 1 hour apart) at any time during labour and after birth;
  • other complications requiring ongoing care.
  • Full-term infant (37-42 weeks) with size appropriate for gestational age
  • Normal cardiorespiratory adaptation to extrauterine life*
  • No evidence of sepsis†
  • Temperature stable in cot (axillary temperature of 36.1oC to 37oC)
  • No apparent feeding problems (at least two successful feedings documented)
  • Physical examination of the baby by physician or other qualified health professional within 12 hours prior to discharge indicates no need for additional observation and/or therapy in hospital
  • Baby has urinated
  • No bleeding at least 2 hours after the circumcision, if this procedure has been performed
  • Receipt of necessary medications and immunization (e.g., hepatitis B)
  • Metabolic screen completed (at >24 hours of age) or satisfactory arrangements made
  • Mother is able to provide routine infant care (e.g., of the cord) and recognizes signs of illness and other infant problems
  • Arrangements are made for the mother and baby to be evaluated within 48 hours of discharge
  • Physician responsible for continuing care is identified with arrangements made for follow-up within 1 week of discharge



†Infants requiring intubation or assisted ventilation, or infants at increased risk for sepsis should be observed in hospital for at least 24 hours

References

  1. Patterson PK. A comparison of postpartum early and traditional discharge groups. Qual Rev Bull 1987;13:365-71.
  2. Norr KF, Nacion K. Outcomes of postpartum early discharge, 1960-1986. A comparative review. Birth 1987;14:135-41.
  3. Yanover MJ, Jones D, Miller MD. Perinatal care of low-risk mothers and infants. Early discharge with home care. N Engl J Med 1976;294:702-5.
  4. Britton HL, Britton JR. Efficacy of early newborn discharge in a middle-class population. Am J Dis Child 1984;138:1041-6.
  5. Britton JR, Britton HL, Beebe SA. Early discharge of the term newborn: A continued dilemma. Pediatrics 1994;94:291-5.
  6. Waldenström U, Sundelin C, Lindmark G. Early and late discharge after hospital birth: Breastfeeding. Acta Paediatr Scand 1987;76:727-32.
  7. McIntosh ID. Hospital effects of maternity early discharge. Med Care 1984;27:611-9.
  8. Arborelius E, Lindell D. Psychological aspects of early and late discharge after hospital delivery. An interview study of 44 families. Scand J Soc Med 1989;17:103-7.
  9. Waldenstrô U. Early and late discharge after hospital birth: Father's involvement in infant care. Early Hum Dev 1988;17:19-28.
  10. Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Problems associated with early discharge of newborn infants. Early discharge of newborns and mothers: A critical review of the literature. Pediatrics 1995;96:716-26.
  11. Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics 1995;96:788-90.
  12. Several states poised to pass early discharge laws. Model legislation would safeguard newborns. AAP News 1996;12:1.
  13. Waldenström U. Early discharge as voluntary and involuntary alternatives to a longer postpartum stay in hospital - effects on mothers's experiences and breast feeding. Midwifery 1989;5:189-96.
  14. Hanvey L. Obstetrics'87, the CMA report on obstetric care in Canada: What have we really learned? Can Med Assoc J 1988;139:481-5.
  15. Conrad PD, Wilkening RB, Rosenberg AA. Safety of newborn discharge in less than 36 hours in an indigent population. Am J Dis Child 1989;143:98-101.
  16. Lee KS, Perlman M, Ballantyne M, Elliott I, To T. Association between duration of neonatal hospital stay and readmission rate. J Pediatr 1995;127:758-66.
  17. De Carvalho M, Klaus MH, Merkatz RB. Frequency of breast-feeding and serum bilirubin concentration. Am J Dis Child 1982;136:737-8.
  18. Rush J, Hodnett E. Community support for early maternal and newborn care (the early discharge project): A report of demonstration projects in Windsor-Leamington and Sudbury 1991-1992. A Maternal-Newborn Initiative. Toronto: Ontario Ministry of Health, 1993.
  19. Stern TE. An early discharge program: An entrepreneurial nursing practice becomes a hospital-affiliated agency. J Perinat Neonatal Nurs 1991;5:1-8.
  20. Arnold LS, Bakewell-Sachs S. Models of perinatal home follow-up. J Perinat Neonatal Nurs 1991;5:18-26.
  21. Zwergel J, Ende ML. Maternal-infant early discharge: Making one home visit count. J Home Health Care Pract 1989;1:16-36.
  22. Norr KF, Nacion KW, Abramson R. Early discharge with home follow-up: Impacts on low-income mothers and infants. J Obstet Gynecol Neonatal Nurs 1989;18:133-41.
  23. Family-Centred Maternity and Newborn Care: National Guidelines. Ottawa: Institutional and Professional Services Division, Health Services Directorate, Department of National Health and Welfare, 1987.
  24. James ML, Hudson CN, Gebski VJ, et al. An evaluation of planned early postnatal transfer home with nursing support. Med J Aust 1987;147:434-8.
  25. Waldenström U. Early discharge with domiciliary visits and hospital care: Parents's experiences of two modes of post-partum care. Scand J Caring Sci 1987;1:51-8.
  26. Waldenström U, Sundelin C, Lindmark G. Early and late discharge after hospital birth. Health of mother and infant in the postpartum period. Ups J Med Sci 1987;92:301-14.
  27. Carty EM, Bradley CF. A randomized, controlled evaluation of early postpartum hospital discharge. Birth 1990;17:199-204.

 

Fetus and Newborn Committee, Canadian Paediatric Society

Members: Drs. Daniel Faucher, Royal Victoria Hospital, Montreal QC; Douglas McMillan (chairman and principal author), Foothills Hospital, Calgary AB; Arne Ohlsson, Women's College Hospital, Toronto ON; Thérèse Perreault, Montreal Children's Hospital, Montreal QC; Michael Vincer, Grace Maternity Hospital, Halifax NS; C. Robin Walker, Children's Hospital of Eastern Ontario, Ottawa ON; and John Watts (director responsible), Chedoke-McMaster Hospitals, Hamilton, ON.
Consultant: Dr. Cheryl Levitt, Chedoke-McMaster Hospitals, Hamilton ON.
Liaisons: Ms. Debbie Fraser-Askin, Neonatal Nurses, St. Boniface Hospital, Winnipeg MB; Drs. Robert Liston, Society of Obstetricians and Gynecologists of Canada, Grace Hospital, Halifax NS; Catherine McCourt, Health Canada, Laboratory Centre for Disease Control, Ottawa ON; William Oh, Committee on Fetus and Newborn, American Academy of Pediatrics, Women and Infants Hospital of Rhode Island, Providence RI; Apostolos Papageorgiou, Neonatal-Perinatal Medicine Section, Canadian Paediatric Society, Jewish General Hospital, Montreal QC.
Principal author: Dr. Douglas McMillan (chairman), Foothills Hospital, Calgary AB.

Maternal Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada

Members: Drs. Karen Ash, Ottawa General Hospital, Ottawa ON; George Carson, Regina General Hospital, Regina SK; Gregory Connors, Foothills Hospital, Calgary AB; Line Leduc, St. Justine Hospital, Montreal QC; Robert Liston (chairman), Grace Hospital, Halifax NS; Francis Sanderson, Regional Hospital, Saint John NB.
Liaison: Dr. Douglas McMillan, Fetus and Newborn Committee, Canadian Paediatric Society, Foothills Hospital, Calgary AB.

Clinical Practice Obstetrics Committee, Society of Obstetricians and Gynaecologists of Canada

Members: Drs. Robert Caddick, Moncton Hospital, Moncton NB; Irene Colliton, Grey Nuns Hospital, Edmonton AB; Ms. Brenda Dushinski, St Joseph's Health Centre, London ON; Drs. Ahmed Ezzat, St Paul's Hospital, Saskatoon SK; Guy-Paul Gagné (chairman), LaSalle General Hospital, LaSalle QC; Catherine MacKinnon, St Joseph's Health Centre, London ON; Nan Schuurmans, Grey Nuns Hospital, Edmonton AB.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.