Week 20 Q&A
A newborn infant is admitted to your service at 1 hour of life after an accidental home birth.
The labor was precipitous and the child’s mother is currently in the operating room for postpartum hemorrhage while the father is in transit from work. The mother was followed by the obstetric team at your hospital, and records indicate this was a healthy and uncomplicated first pregnancy for her. The infant appears robust and healthy on exam.
Which of the following will occur during the infant’s hospitalization?
A. Administration of hepatitis B vaccine.
B. Hearing screen.
C. Ortolani and Barlow measures.
D. Warming of the child, if necessary, and monitoring of vital signs.
E. Screening for hyperbilirubinemia.
F. All of the above.
The correct answer is “F.” In general, “all of the above” is usually a safe choice within this book. Newborns are newborns and have the same care requirements regardless of where they were born. Within 24 hours of birth, newborns should have a full head-to-toe exam while naked. To ensure that you focus on each aspect of the exam, think of your goal as finding a minor defect. Make sure the red reflex is symmetric, present in both eyes, and not white (leukocoria). If not, call ophthalmology to look for cataracts, retinoblastoma or other pathology. Perform Ortolani and Barlow maneuvers when examining the hips to check for developmental dysplasia of the hips (DDH). Risk factors include breech positioning, female sex, and family history. If missed, it can lead to pain and osteoarthritis. Hip “clicks” are benign, common, and not associated with DDH; they are due to ligamentous laxity. All newborns should receive vitamin K injection, erythromycineye ointment, hepatitis B vaccine, hearing screen, and metabolic screening. Screen for hyperbilirubinemia (jaundice) between 24 and 48 hours of life—obviously earlier is okay if the infant is glowing (yellow). Pulse oximetry screening for critical congenital heart disease should be completed after 24 hours. Risk factors for sepsis should be identified. Although home births in the United States are rare, the number is increasing. Infant mortality appears to be two to three times more prevalent in home births than hospital births in the United States, but small international studies showed no increase in neonatal mortality when a registered midwife or physician was in attendance, as their criteria require, suggesting that the process can be made safer. Considerations in home birth include the following: pregnancy should be uncomplicated, and there should be a certified midwife or physician currently practicing within a regulated health system, and at least one NRP-trained individual in attendance whose primary responsibility following delivery will be the infant. Proximity to a hospital with specialty services is also highly recommended, as travel times greater than 20 minutes have been associated with higher adverse outcomes for the infant, including mortality.