Posts Tagged ‘Early discharge’

At the rate things are going I’m going to have to brush up on post-operative recovery skills, not because I’m going to be working back in the hospital, but because my women are being discharged earlier and earlier post caesarean section. Just a few years ago a 5 day stay was routine, then 4 and now it’s day 2, how long before they walk out of the operating theatre and get straight into the car to come home?

C-section is now viewed as just another option in the childbirth choices. It is that but it’s the just  which is inaccurate, it is a major operation. If you are not squeamish then watch the video and appreciate the invasive nature of this major surgery.

In some cases caesarean section is a life-saving procedure, in many it was defensive practice. Over the past 15 years the C-Section rate has more than doubled BUT there has been no decrease in maternal morbidity or mortality, in fact it may even be stationary with researchers in the USA concluding that caesarean section quadruples a woman’s risk of dying.

How much higher is that risk going to be when leaving the hospital earlier and earlier?

Which poses more risk to women and babies, caesarean section or homebirth?

Don’t even get me started on the possible risks to the baby during and following a c-section for non-medical reasons.

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I’ve been musing, and I’ve come to an earth-shattering decision, early discharge from hospital after giving birth should not be encouraged. I can sense much sharp in-taking of breath, I know, it’s pretty radical stuff, now I’m going to explain myself.

Recently I made a day 5 visit, that’s the day we reweigh baby and take the neonatal blood screening test (aka heel prick; guthrie; PKU). This was the couple’s first baby, born by emergency CS, 2 day hospital stay, second visit by a community midwife. They had phoned before I left the office to ask what time a midwife would be visiting  as they had seen some ‘blood’ in baby’s nappy and were worried, I told them that I would make them my first visit and asked them to save the nappy. Mum and Dad had been to NCT classes so, when having looked at the nappy, I told them that it was normal and was urates from his urine they then produced an A4 handout they had been given, which showed photos of what they may see in early nappies! Having addressed the blood in the nappy worry I had a look at her notes, useless, the hospital had kept her inpatient notes so I had no idea how things had gone for either of them whilst in hospital. The midwife who had visited before me had recorded that Mum as recovering well, her scar was clean and dry, baby was breastfeeding, passing urine and meconium. I glanced at baby and saw a ‘worried’ looking baby. Worried. This is my description of an underfed baby, they do all seem to have this little sad expression, a furrowed brow, very difficult to describe but when I see it it makes me worried. I decided to examine his Mummy first and remove her suture  before I had a good look at, and weighed him, I had a feeling that she may be somewhat agitated after I had examined her little baby. I should say more agitated as she was extremely anxious about having her suture removed, but my incessant talking worked it’s usual magic and the stitch was out before I could finish my life history. As I undressed baby I asked her about feeding, she was breastfeeding, basically when she thought that he should feed, this was equalling about three times a day. I gave them my usual spiel “It’s normal for babies to have lost up to 10% of their birthweight ……..we plan what happens next on how baby is, what the nappies are like etc. might just come back in 48 hours if all seems well and re-weigh then to make sure that baby is putting on weight but we might ask them to go into hospital to have baby checked by a paediatrician”. Baby’s mouth was very dry, his skin was like an old persons, there was no elasticity, his poo was sticky and green. He really wasn’t bothered about me undressing him, a floppy little boy. As I put him on the scales he showed his startle reflex, little arms and legs shot out star-like, his eyes opened wide, even those seemed dull, and his cry sounded as if he had been screaming for hours, it was hoarse. The results of the weighing were not good, he had lost nearly 20% of his birthweight. I explained to the concerned parents that I would be happiest if he were seen by a paediatrician but, first things first, get some nourishment into him. He was awake and trying to latch onto my arm so I asked Mum to get comfy and we would put him to the breast, once he was feeding I could then contact the hospital he was born in, not one I work for. Basically the attempt at feeding was not a success, Mum obviously had no idea how to breastfeed and it really didn’t help that baby was so malnourished that even hunger was not going to keep him awake. I showed her how to hand-express into a sterile syringe and I went through the long process of referring him to the hospital. I nearly lost the will to live at one point, I considered hanging up on the officious, series of people I was put through to and just send them to the hospital I work for. In the end I resorted to the unspoken threat,’ Since you can’t seem to help, can you put me through to the head of midwifery?’ Works a treat, I was told that baby would be seen on SCBU.  On admission he was found to be severely dehydrated with dangerously high sodium levels; he was immediately put on an IV and a tube was passed into his tummy so that he could be fed easily. He remained in hospital for 8 days.

Following their second discharge from hospital I visited again. By this time baby was still not back to his birthweight, but was a different little man, alert, bright-eyed and peachy skin. His Mum was still anxious, and no wonder, she had spent over a week in a Special Care Baby Unit watching her newborn be jabbed, infused, and tube fed.

That’s the background to my desire to encourage women to stay in hospital for longer after giving birth. My concerns about this ‘early discharge’ culture has been growing gradually over the years, every week I come across examples of where a longer stay would have been beneficial but this latest one has been the most extreme. The couple involved were educated, one was medically qualified. They had attended NCT classes, hospital antenatal classes and breastfeeding ‘workshops’  but none of this theory had adequately prepared them to successfully nurture their first baby. The ward the woman was cared for on was safely staffed but this does not necessarily mean that there was time for staff to ensure that baby was feeding well, or time to reassure anxious first-time parents. The short stay meant that it was not evident prior to discharge that baby wasn’t breastfeeding successfully. WHO wish to promote exclusive breastfeeding, to be successful some women require more support than ‘workshops’ during the antenatal period, they would benefit most from a slightly longer stay in an establishment where there are enough staff to provide assistance and reassurance.

Guess what it is that has caused the early discharge culture? It’s staffing levels, the closure of smaller maternity units and the resultant loss of ‘beds’. What causes all this? Cutbacks. It’s a false economy though, I’m not talking the small cost here of re-admissions, like my example above, I’ll just reproduce the opening paragraph from WHO’s ‘Promoting proper feeding for infants and young children’ and it’s easy to see that a cutback in the maternity services has lifelong health implications.

‘Nutrition and nurturing during the first three years are both crucial for lifelong health and well-being. In infancy, no gift is more precious than breastfeeding; yet barely one in three infants is exclusively breastfed during the first four months of life’. (World Health Organisation)

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