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Minnesota Health Technology Advisory Committee. Minnesota Health Technology Assessments [Internet]. St. Paul (MN): Minnesota Department of Health; 1995-2001.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Post-Delivery Care and Stabilization of Mother and Newborn

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Executive Summary

Introduction

The timing of hospital discharge following delivery has become a focus of concern in providing appropriate postpartum care for both mother and infant. Although the trend toward earlier discharge was originally consumer driven during the 1970's as a means of focusing on child birth as a family centered experience, current motives for early discharge are largely driven by changes in the primary function of hospitals and by a perception that insurers will not cover longer stays.

The term “early discharge” reflects the fact that hospital stays used to be considerably longer in previous years. However, it is not meant to imply that longer stays are necessarily better. Early discharge has been defined in various ways in the literature, generally referring to a length of stay between one and two days after delivery. In actual practice, a one day stay may be 13-35 hours, depending on when the mother delivers. A patient who delivers at 11:00 p.m. for example, might be discharged at noon the following day (13 hour stay). A patient who delivers at 1:00 a.m., however, might not be discharged until noon the next day (35 hour stay).

Minnesota statistics demonstrate a trend toward early discharge. In 1985, only 6.2% of infants in the Twin Cities metropolitan area (delivered vaginally without complications) were discharged at one day after delivery, while first quarter 1995 statistics indicate that 42.5% of infants were discharged at one day.

As current health care practices require patients to play a more active consumer role in their care, this report attempts to identify the issues surrounding early discharge as they relate to the health and well being of the mother and infant. Recently, legislation has been passed mandating that insurers pay for a minimum of 48 hours of hospitalization following delivery. In actual practice, however, the optimal time of discharge cannot be established independent of a continuum of care from the prepartum through the postpartum period. This report attempts to identify the medical, physical, social, emotional, and psychological issues related to the appropriate care of mother and baby in the postpartum period, with the objective of reframing the debate from a discussion of discharge timing to a focus on the care that mothers and newborns should receive in the post-delivery period.

Issues

The length of time between delivery and discharge from the hospital is an important issue at this time. Recent legislation mandates insurers to provide coverage for a hospital stay of 48 hours following uncomplicated vaginal delivery. This report addresses the following issues as they relate to timing of discharge:

  • Medical and physical issues for the newborn
  • Medical and physical issues for the mother
  • Social, emotional, and psychological issues for the mother and newborn
  • Cost comparison of early versus later discharge

A glossary of terms has been provided in Appendix I of this report.

Summary of Literature

Most published studies related to length of stay following delivery describe outcomes of specific programs, each having particular and unique characteristics. Furthermore, socio-economic factors, geography, nationality, ethnicity, birth setting, and other population characteristics vary widely, as do criteria for determining an infant's candidacy for early discharge. As a result, it is often difficult to compare data from different reports or to generalize results from one program to other settings. Most published reports have included only small groups of infants. Because groups are small and adverse outcomes are rare events, a single additional readmission in either early or late discharge groups could, in many cases, affect the overall outcome of the study. In addition, data from the available literature may be outdated and reflect practices that have changes. More research is needed to address this issue. Appendix II provides a summary of articles.

Medical/Physical Issues of the Newborn

  1. With discharge within one or two days after delivery, there may not be adequate time for recognition of serious illnesses while the newborn is in the hospital. Although some problems may become evident soon after birth, other problems such as jaundice, heart malfunctions, and intestinal difficulties take longer to become apparent. It is important that discharge programs provide mechanisms to detect and treat problems that do not present until after the patient leaves the hospital.
  2. The literature is inconclusive regarding the effect of discharge within one or two days on rehospitalization rates. Most studies do not have a sufficient number of patients to be statistically significant, and results vary depending on the particular populations studied and the extent of follow-up that is provided. Infants may be readmitted to the hospital for many reasons, including: jaundice, breathing problems, heart irregularities, hypothermia, infection, feeding and circumcision problems.
  3. Minnesota requires that all infants be screened for a number of diseases. Screening performed less than two days after delivery may cause some screening test results to be invalid, and those tests will have to be repeated. The expense and difficulty involved in tracking down infants for retesting should be recognized and addressed as barriers to optimal screening. In Minnesota, it is the legal responsibility of either the administrative officer or other person in charge of each institution caring for infants 28 days or less of age or the person required to register the birth of the child to administer these tests and file the required information with the Minnesota Department of Health. Since optimal screening may, in some cases, occur after the baby leaves the hospital, it is important that early discharge plans incorporate screening into their guidelines.
  4. In order to care for themselves and their infants, mothers need to be knowledgeable in a number of areas. However, mothers may be least able to assimilate new information in the time immediately following delivery. Early discharge programs should ensure maternal/family readiness to assume responsibility for the newborn through demonstrated skill and ability in feeding techniques, skin and cord care, and the ability to assess infant well-being and seek timely, appropriate treatment.
  5. The hospital environment may pose risks to the health of both mother and infant, due to the prevalence of nosocomial infection. When weighing the benefit of increased hospitalization, one must take into account the risk of infection due to hospital-acquired diseases.

Medical/Physical Issues of the Mother

  1. Mothers with normal pregnancies and deliveries generally experience a healthy postpartum course regardless of the time of discharge. Although maternal complications are rare, they do occur, and need to be detected promptly so that mothers can return to the hospital for treatment. There are a number of reasons why mothers may be readmitted to the hospital, including inflammation of the uterus and late postpartum hemorrhaging. Less serious maternal problems may be related to perineal bruising, discomfort and hemorrhoids, or breast-related symptoms. Mothers need to be informed of potential complications and their symptoms so they can seek timely, appropriate treatment.
  2. The literature is inconclusive regarding the effect of early discharge on breast-feeding. Earlier discharge does reduce the time available for teaching and support on breast-feeding in the hospital after delivery; some programs compensate for this by providing instruction during the last trimester or in the home environment following the birth. Since the milk supply is generally not established at 24 hours after delivery, and may not be established at 48 hours after delivery, it is important that all mothers receive appropriate education and support for breast-feeding.
  3. Regardless of time of discharge, typically, mothers will experience fatigue in the first several days after delivery. Adequate support must be available during this time to assist the mother in caring for her new infant.
  4. The hospital environment may pose risks to the health of both mother and infant, due to the prevalence of nosocomial infection. When weighing the benefit of extended hospitalization, one must take into account the risk of infection due to hospital-acquired diseases associated with post-delivery care.

Social, Emotional, and Psychological Issues

  1. The literature is inconclusive regarding the relationship between early discharge and postpartum depression.

    Discharge plans need to recognize the potential for postpartum depression among new mothers, and put mechanisms in place to detect it and treat it should it arise.
  2. Fatigue will be a factor in the days immediately following delivery regardless of the timing of discharge. In addition to affecting the mother's physical status, fatigue will also impact the mother's emotional and psychological readiness to care for her new baby. Mothers without strong support systems in the home environment may be particularly ill-equipped to deal with the rigors of caring for a newborn. Care plans need to assess the home environment as well as the physical condition of mother and newborn.
  3. Many studies mention other aspects of emotional health such as mother-baby bonding, but do not provide data to support or refute a relationship between bonding and time of discharge. However, separation of mother and child in hospitals for medical reasons or discharge of one or the other is viewed as detrimental to bonding.
  4. Other issues for which little data exist include the current state of community support systems, such as home care nursing, available routine and emergency transportation, telephone support, support from the family unit (such as father and siblings), and other support systems available to the mother after discharge.

Cost Comparison of Early Versus Later Discharge

  1. Significant cost savings may be achieved from shorter post-delivery hospital stays. However, this must be weighed against the potential costs associated with readmission and emergency care. In addition, costs of other prenatal and postnatal care (such as home visits or additional office visits) associated with an early discharge must be factored in to the analysis, as well as costs generated by the treatment of nosocomial infection. The risks and costs of prolonged hospitalization need to be weighed against the risks and costs associated with early discharge. Further research needs to be done in order to draw any conclusions regarding the cost implications of the timing of discharge.
  2. HTAC reviewed the post-delivery care literature for findings from cost effectiveness analysis, which measures the relationship between the cost of care and the benefit that is derived from it. However, data are insufficient to draw conclusions regarding the cost effectiveness of early versus later postpartum discharge.

Outstanding Issues

Many issues related to early discharge of mother and infant have yet to be addressed adequately in the literature, including:

  • How is health plan coverage interpreted, translated, communicated, and applied in the delivery site? There is an apparent lack of continuity between the discharge criteria of insurers and the actual practice of hospitals. Dialogue between payers and providers may clarify misunderstandings on this issue.
  • Where should follow-up after discharge occur (hospital, clinic, home) and how does continuum of care throughout the postpartum period vary with time of discharge?
  • How can fail-safe newborn screening take place when infants are discharged early?
  • Issues related to rural mothers and infants have not been addressed. For example, response time for medical emergencies after discharge from the hospital, the availability of technologies and resources in the rural community, and staffing costs in a rural hospital setting are all issues that would have an impact on discharge planning for rural mothers and newborns.
  • Is there a relationship between socio-economic status and post-delivery length of stay? This may be of special interest for post-discharge planning where there are fewer resources to assist the mother.
  • Patient satisfaction related to early discharge should be explored more thoroughly. What emphasis should be placed on the importance of patient preference?
  • Who gets readmitted into the hospital? Are there differences in maternal readmission rates after first versus subsequent births?
  • The role of hospitals has changed over time. Previously, hospitals served many purposes (treatment, rest, observation, etc.). Currently, hospital stays are used for those requiring intensive evaluation or treatment. Should an intermediate setting for care and services be considered?
  • Appropriate education and follow up services (including screening) are also necessary for families who deliver outside of the hospital setting (i.e., at home).
  • The economic ramifications of early discharge need to be addressed in a larger context so as to capture all relevant information.
  • Discharge planning for more complicated deliveries, such as cesarian section, should also thoroughly evaluate the individual needs of each mother and infant.

Conclusions

To date, data are inconclusive in demonstrating either a positive or negative correlation between optimal outcome of pregnancies and length of stay following delivery. Local and community-wide research to address many of the concerns related to the timing of discharge are needed.

The birth of each child is unique, with a multitude of factors (e.g., physical status of mother and infant, availability of social support at home and in the community, resources within the hospital) affecting the outcome. To ensure optimal care for both mother and child, the time of discharge should be determined on an individual basis. Care systems need to develop appropriate programs to meet the unique needs of their patients within the context of their communities. Individualized discharge plans can and should be established through medical assessment and community resource assessment.

Care is not adequately measured in terms of hours. The needs of each mother and baby must be assessed on an individual basis, and care delivered in a manner that makes the most sense for each unique birth situation. Therefore, a legislative mandate of any minimum requirement of length of stay cannot assure optimal care. Instead, focus on the continuum of care for the mother and baby, and emphasize the importance of establishing appropriate plans for the post-delivery care and stabilization of mother and newborn is needed.

The guidelines put forth by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology may serve as a basis for meeting the minimum discharge criteria. See the Conclusions section of the full report for the specific discharge criteria recommendations.

Technical Report

Background

Early discharge has been defined in various ways in the literature, generally referring to a length of stay between 24 and 48 hours after delivery. In actual practice, a length of stay may be 13-35 hours, depending on when the mother delivers. A patient who delivers at 11:00 p.m. for example, might be discharged at noon the following day (13 hour stay). A patient who delivers at 12:05 a.m., however, might not be discharged until noon the next day (35-hour stay). The American Academy of Pediatrics defines “early” and “very early” discharge as stays of 48 and 24 hours or less, respectively, after uncomplicated vaginal delivery.1

Hospital discharge following delivery has become a focus of concern in providing appropriate postpartum care for both mother and infant. Although the trend toward earlier discharge was originally consumer driven during the 1970's as a means of focusing on child birth as a family centered experience, current motives for early discharge are largely driven by changes in the primary function of hospitals and by a perception that insurers will not cover longer stays.

Minnesota statistics for the 7-county metro area mirror this trend. In 1985, 6.2% of infants delivered vaginally without complications were discharged at one day, 53.5% were discharged at two days, and 33.8% were discharged at three days. In contrast to this, the 1995 first quarter statistics indicate that 42.5% of infants were discharged at one day, 47.5% were discharged at two days, and 7.9% were discharged at three days.2

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Opinion varies widely regarding the desirability of early-discharge practice.4 Proponents of early discharge claim that it is safe and may be advantageous from both a medical and psychological standpoint. Opponents, on the other hand, argue that an element of risk may be involved because detection of significant illness may be either missed or delayed outside of the hospital. To further complicate the issue, economic considerations often constitute a driving force behind the trend to earlier discharge.3

Still, others argue that appropriate postpartum care is not related to the timing of discharge. Instead, the issue is the patient's condition at discharge and the services available once a mother arrives home with a newborn baby.5 They further suggest that a decision for early discharge should be individualized and should be a mutual decision between the patient, her family, and obstetrical provider.6

As current health care practices require patients to play a more active consumer role in their care, this report attempts to identify the issues surrounding early discharge as they relate to the health and well being of the mother and infant. Recent legislation has been passed mandating that insurers pay for a minimum of 48 hours of hospitalization following delivery. In actual practice, however, the optimal time of discharge cannot be established independently of a continuum of care from the prepartum through the postpartum period. This report attempts to identify the medical, physical, social, emotional, and psychological issues related to the appropriate care of mother and baby in the postpartum period, with the objective of reframing the debate from a discussion of discharge timing to a focus on the care that mothers and newborns should receive in the post-delivery period.

Review of the Evidence: Continuum of Postpartum Care

Summary of Literature

Most published studies on early discharge describe outcomes of specific individual programs, each with its own particular and often unique characteristics.(3) Socioeconomic factors, geography, nationality, ethnicity, birth setting, and other population characteristics vary widely, as do criteria for determining an infant's candidacy for early discharge. Varied methods of risk screening and parental education have been utilized, maternal support systems at home differ widely, and mechanisms of follow-up vary fromphone calls to home and office visits. The definition of early discharge differs considerably among studies: infants discharged in the“late” group in one study may actually gohome atan earlier postnatal age than the “early” group of another. As a result, it is often difficult to compare data from different reportsor to generalize results from one program to other settings. Appendix II provides a summary of articles reviewed.

Medical/Physical Issues for the Newborn

Psysiologic Stability

An important advantage to earlier hospital discharge is that nosocomial (hospital-acquired) infection is minimized for both infant and mother.7 However, this must be weighed against the risk that early discharge may not provide adequate time for routine medical and social assessment of the mother-infant dyad.8

The Committee on Fetus and Newborn of the American Academy of Pediatrics9 recommends that the hospital stay of the mother-infant dyad should be long enough to allow identification of problems and to ensure that the family is able and prepared to care for the baby at home. Many cardiopulmonary problems related to the transition from an intrauterine to an extrauterine environment become apparent during the first 12 hours after birth. However, other problems such as jaundice, ductal-dependent cardiac lesions, and gastrointestinal obstruction may require a longer period of observation by skilled personnel.

Norr and Nacion,10 in their comparative review, observed that although infants discharged early are rehospitalized more often than their mothers, their rehospitalization rate is still low. Infant readmission rates vary a great deal from one program to another, in contrast to the relative stability of maternal readmission rates. In the Norr study, almost all of this variability reflected differences in the definition and treatment of hyperbilirubinemia. Other reasons for readmission included: transient tachypnea, bradycardia, and hypothermia.

Other studies11 reconfirm that treatment of jaundice with phototherapy is the most frequent cause for readmission in some hospitals. Additional reasons for readmission include; respiratory, feeding, bacterial and viral infection, and circumcision problems. In a study by Pittard and Geddes,12 suspected infectious disease was overwhelmingly the major cause for readmission; while hyperbilirubinemia was rarely the reason for readmission. Maternal age, race, and parental financial status were not predictors of early infant readmission in this study. The high variability in readmission rates for jaundice, historically the most significant reason for readmission, suggests that hospitals can sharply affect their readmission rates for newborns by changing their management of hyperbilirubinemia.

The criteria delineated to measure physiologic stability for infant discharge from the University of Colorado Health Sciences are reported by Conrad.11 The criteria for early discharge were:

  • Apgar scores at 1 and 5 minutes are >7.
  • The infant is term (38-42 weeks) and weights 2700 to 4000 grams.
  • Minimum stay of 24 hours, transition to normal thermoregulation in an open crib, completion of two successful feedings, evidence of stool and void, completion of neonatal screening for metabolic disease and blood type and Coomb's test (Rh- and O mothers) prior to discharge.
  • Vital signs are within normal ranges at discharge:
    - Axillary temperature: 36.1EC to 37.2EC
    - Heart rate: 110 to 150 beats per minute
    - Respirations: 25/min. to 60/min.
  • The infant has a normal hospital course and resents no signs or sumptoms that require continuous observation.
    - Blood dextrose concentration maintained >2.5 mmol/L
    - Hematocrit 0.45 to 0.65
    - Infants with ABO-incompatible infants must be held for 48 hours and released only if they do not require therapy for hemolysis.
  • Physical examination completed by house officer.

Although infant mortality has not been reported in relationship to early discharge, 1994 Minnesota health statistics indicate that infant mortality rates decrease after the first day of birth. Of 64,277 live births, 296 resulted in neonatal deaths, 189 in first-day deaths (largely associated with low birth weight and congenital anomalies), and 57 in 1-6 day deaths. See Appendix IV for distribution of causes of death.

Screening

Screening programs are designed to prevent morbidity and mortality through early diagnosis of medical problems and congenital disorders that can have serious sequelae. Adequate screening programs require universal participation, prompt diagnosis, and mechanisms for parental notification and education. Common screening tests include: phenylketonuria, galactosemia, maple syrup urine disease, congenital adrenal hyperplasia, and congenital hypothyroidism. Some states also mandate screening for sickle cell disease and various sexually transmissible infections.13

The screening samples are generally designed for samples taken on the second or third day of life. Screening performed less than two days after delivery may cause some screening test results to be invalid, and those tests will have to be repeated. If screening is done too soon, not only will it be necessary for infants to be retested, there is the danger that those administering the screening program will assume incorrectly that the results of these screening tests are reliable. If the infant leaves the hospital before all necessary screening tests have been administered, follow-up screening must be completed in a timely fashion, no later than two weeks after birth.14

Minnesota Statute 144.125 states that all Minnesota newborns shall be tested for the following diseases: phenylketonuria (PKU), galactosemia, hypothyroidism, hemoglobinopathy (sickle cell disease) and adrenal hyperplasia.15 Three of the five tests (PKU, hypothyroidism and adrenal hyperplasia) are not reliable if performed less than 48 hours post-delivery.

The statute further states that it is the duty of the 1) administrative officer or other person in charge of each institution caring for infants 28 days or less of age and 2) the person required to register the birth of the child to administer these tests in accordance with the rules prescribed by the state commissioner of health.16

The duties of the responsible party include: informing parents or guardians that their newborns will be screened and providing explanation for the screening and their rights to refuse; collecting a specimen for screening no later than the fifth day after the infant's birth; if samples have been taken prior to 24 hours after birth, notifying the parents or guardians verbally and in writing of the necessity of having the Phenylketonuria test repeated on their newborns no later than the 14th day of life; recording the date the specimen is collected in a permanent record; and sending the specimen card including all required information to the Minnesota Department of Health.16

Care of Newborn

The American College of Obstetrics and Gynecology17 (ACOG) recommends that early or very early discharge with regard to care of the newborn should ensure maternal readiness to assume independent responsibility for her newborn through demonstrated skill and ability in feeding techniques, skin and cord care, measurement of temperature with a thermometer, and ability to assess infant well-being and recognize common neonatal illnesses. Family members who will care for the child should attend prenatal childbirth education or infant care classes, in which problems of the first days after birth are discussed.

Medical/Physical Issues for the Mother

Carty and Bradley18 observed that regardless of the time of discharge, the women in their study generally experienced a healthy postpartum course. However, serious complications can and do occur. In the study by Norr and Nacion,10 the majority of maternal readmissions were for late postpartum hemorrhages. Thurston, et al19 indicated that less severe maternal problems were most commonly related to perineal bruising, discomfort and hemorrhoids, or to breast-related symptoms.

Although large prospective studies are lacking, some studies indicate significant medical problems in 4.3% of early discharge patients with readmission rates as high as 1.8%.20 These complications suggest the need for a planned program of follow up and the responsibility to teach patients the warning signs and symptoms for potential problems.

The American Academy of Pediatrics and American College of Obstetrics and Gynecology14 recommend that prior to discharge, the patient should be informed of normal postpartum events, including the changes in the lochial pattern that she should expect in the first few weeks; the range of activities that she may reasonably undertake; the care of the breasts, perineum, and bladder; dietary needs, particularly if she is breast-feeding; the recommended amount of exercise; emotional responses; and observations that she should report to the physician (e.g., temperature elevation, chills, leg pains, or increased vaginal bleeding).

Additionally, the length of convalescence based on the type of delivery should be discussed, and patients should be counseled to avoid abdominal straining. Patients who have abnormal bleeding or signs of infection or fever should not be discharged. It is helpful to reinforce oral discussion with written information.14

Breast-feeding

Some researchers suggest that early discharge may foster enhanced breast-feeding.3 In a Swedish study by Waldenstrom,21 infants discharged early were breast-fed significantly more often on the third and fourth days postnatally than those staying in the hospital, although no difference in incidence of breast-feeding was observed during the subsequent 10 days. Carty and Bradley18 reported that a significant difference in breast-feeding was observed between the early discharge group and the traditional stay group. At one month, 87% of the women in the early discharge group and 79% in the traditional group were giving their babies breast milk only.

According to a study by Waldenstrom,21 however, cited differences in breast-feeding rates may be more related to differences among women studied rather than to the day of discharge.

Social/Emotional/Psychological Issues for Mother and Newborn

The impact of early discharge on the emotional health of the mother is an important area of concern. Emotional health includes such things as postpartum depression, mother-child separation, the mother's confidence in her ability to be a good parent, stress management, and the need for external support.13

In a randomized, controlled study, Carty and Bradley18 compared discharge at 12-24 hours, 25-48 hours, and four days. The mothers discharged 12-24 hours after giving birth reported themselves to be significantly less depressed at one month postpartum than the two later groups. In addition, the earliest group reported higher levels of confidence at one week postpartum than the other two groups. At one month postpartum, however, the three groups did not differ significantly with respect to levels of confidence.

A study by Beck, et al22 reports that the lack of any significant difference exhibited between two groups of primiparas regarding the incidence of maternity blues and postpartum depression lends support to the notion that early discharge programs are psychologically safe.

Another study by Romito and Zalate023 also reports, “the results show that there was no difference in the two groups in the postpartum period as regards tiredness or depression. Both groups felt most tired during the days immediately following discharge, whether discharge was 1 or 6 days after birth.

A document commissioned by Maternal and Child Health Bureau reports on an October 1994 consensus meeting in Boston. There, a group of experts with “intimate knowledge of both hospital and community-based care for mothers and newborns” found that “women who are from high-risk social environments and with limited social support structures may not be best served by a one-day stay.” In addition, “separation due to the need to observe either the mother or the newborn was deemed unacceptable.” Policies that would result in increased rates of separation were viewed by the group as detrimental to mother/infant bonding, infant and maternal health, and threatening to breast-feeding. Clinicians recognized a distinction between 24 hours and 72 hours because mother/infant bonding occurs during this early critical time period.24

Although many other studies mention aspects of emotional health such as mother-baby bonding and the mother's support system, they do not provide data.13 Other issues for which little data exist include the current state of community support systems, such as home health care nursing, available transportation, telephone support, and other support systems available to the mother after discharge from the hospital.

Conrad11 comments that illiteracy, young maternal age, lack of transportation, and inability to defray the cost of prenatal care may serve to limit prenatal child care education and medical care for women in lower socioeconomic groups. Single-parent status may limit support at home. Provision of health care through several ambulatory systems as well as frequent household moves and a lack of telephone service compromise the establishment of optimal follow-up in the postpartum period. These problems could serve to limit the applicability of early newborn discharge, as outlined by the AAP and ACOG, to large segments of the population that otherwise meet the medical criteria.

Education

Braveman1 points out, “Early discharge has reduced the time available for in-hospital teaching and support on breast-feeding, infant care, women's health needs, and family planning, and for maternal and family psychological assessment.” For this, Beck21 suggests, “What early discharge programs need to routinely include are teaching sessions during the last trimester which focus on postpartum discharge instructions for mothers and babies such as episiotomy care and umbilical cord care.”

In contrast to this, Harrison25 suggests that education may be more effective and appropriate in the home environment following the birth: “Compared with the hospital environment, the home may provide more opportunities to include other family members in the teaching program. In addition, parents are often more ready to learn in their home environment, after they have had a chance to assume responsibility for their infant's care.”

Cost Comparison

Financial saving and more optimal utilization of health care resources are often cited as advantages of early discharge, yet published studies vary in their conclusions with respect to these issues.3 In a one-year study (1993) of 26 New Hampshire hospitals, the financial impact of early versus later discharge was calculated using the mean pediatric charge excluding perinatal condition. In this population based study using 15,000 annual births, approximately 24% of infants qualified for early discharge and were discharged in less than 48 hours after delivery.5

In a letter submitted to the Congressional Record regarding the New Hampshire study, Frank reported, “The total charges for those infants who were discharged early and required readmission or ER visits were approximately $183,000. The total charges for one additional day for the mother infant dyad discharged early were approximately $7,466,000. Thus the saving for the health care industry was approximately $7,283,000.”5

In an article reviewing Frank's study, Seal26 cautioned that the study id not look at additional costs for prenatal and postnatal care provided by some health care facilities to accompany early discharges. For example, St. John's Hospital and Health Center reports that they have incurred some additional nursing costs in order to intensify new mother education.

Yanover, et al27 compared 44 early discharge mothers with 44 receiving traditional care at Kaiser-Permanente Medical Center, San Francisco. Their observation was “we estimate that the cost of providing our program's services is approximated by the immediate saving derived from early discharge. The expenses include salaries of nurse practitioners, paramedical personnel, and medical consultants, as well as automobile expenses and home-care supplies.”

Gonzalves and Hardin28 reported on the cost effectiveness of the Irwin Army Community Hospital early discharge program. Data was collected from a retrospective audit of outpatient records for the period from November 15, 1991 through May 31, 1992. In this trial program they concluded, “Cost effectiveness was demonstrated in bed days saved and the ability to implement other cost-saving initiatives as a result of this program. A total of 788 bed days valued at $705,260 were made available for use by other patients (cost per hospital day is $477.50 per patient). The additional nursery beds were utilized to return premature infants from local tertiary centers to our facility an average of 6 days earlier than before our program was instituted. An approximate cost avoidance of $224,350 was realized as a result of this action.”

Recommendations for PostPartum Care

The following are recommendations put forth by various organizations regarding optimal postpartum care.

The American College of obstetricians and Gunecologists

The American College of Obstetricians and Gynecologists (ACOG) believes that changes in practice such as early discharge following obstetrical delivery should be based on sound scientific data that demonstrate good outcomes for mother and infant, as well as being cost effective. As yet, these data do not exist.17

ACOG acknowledges that selective, early discharge is safe and desirable for some mothers and babies. However, a decision for early discharge should be individualized and should be a mutual decision between the patient, her family, and the obstetrical provider - taking into account medical risk factors, support systems for the family, and the readiness of the mother to care for herself and her newborn.

ACOG supports legislation addressing insurance coverage for postpartum care that meets the following criteria:

  • The appropriateness of individual discharges is left to the discretion of the physician and patient.
  • The Guidelines for Perinatal Care provides the basis for required coverage.
  • Patients are not provided incentives or disincentives by insurers to access care that is inconsistent with the Guidelines for Perinatal Care.

The American College of Nurse-Midwives

The American College of Nurse-Midwives (ACNM) position is that the timing of discharge after birth is a clinical decision determined by the patient's medical condition and circumstances, the content and quality of prenatal care, the conduct of labor and birth, the newborn's condition, and the availability of qualified personnel to provide early post-partum and newborn assessment. Many women and their newborns are appropriate candidates for early discharge, and payers should be flexible in the decision regarding timing of discharge.

The ACNM will welcome what it and others would embrace as a balanced and broad-reaching Newborns and Mothers Health legislation by which no clinician would be forced to fight for care that is safe, and no mother forced to return home before receiving adequate medical, physical and social support to care for herself and her baby.6

Minnesota Medical Association

The Minnesota Medical Association (MMA) passed a resolution at its most recent annual meeting stating that an appropriate postpartum length of stay and any required follow-up care, including nurse home visits, should be determined by the physician and patient and not by an arbitrary time integral. The resolution also indicated that the MMA opposes mandatory reduced hospital stays of one day for vaginal delivery, and three days for cesarean sections (the day of delivery being defined as day 0).29

American Medical Association

The American Medical Association (AMA)is concerned that managed care's practice of requiring routine early discharge for newborns and their mothers may be dangerous to the health and well-being of the mother and child. The decision of when to leave the hospital should be left to the physician and patient and not be based solely on the financial considerations of the managed care company. S. 969 would provide reasonable protection for mothers and their babies so that they are not forced to leave the hospital before it is safe to do so.30

Minnesota Nurses Association

The Minnesota Nurses Association (MNA) has also passed a resolution regarding postpartum hospital stays. Their position is that legislation mandating 48-hour hospitalization does not address the need for assessment of anticipated problems in the postpartum period and education of parents. The maternal and child health Registered Nurses in the hospital settings have the ability and responsibility to assess for complications and plan necessary education and post-hospital referrals. Discharge timing should be a mutual decision made by the family and their health care providers including registered nurses.

Therefore, the MNA supports state and federal policies which create incentives for the insurance industry to provide adequate coverage for maternal-child health care, based upon individual need including a length of stay, as determined by the client with the Registered Nurse, Certified Nurse Midwife, or Physician. In addition, the MNA supports state and federal policies which would require third party payers to cover a minimum of two home visits by a Public Health or Registered Nurse with expertise in community and maternal child health nursing.31

American Academy of Pediatrics

The American Academy of Pediatrics' Committee on Fetus and Newborn9 have developed minimum criteria for newborn discharge. These criteria are set forth on page 22.

American Academy of Family Physicians

The American Academy of Family Physicians (AAFP) adopted a resolution in September 1995 stating that the AAFP reaffirms physician authority for decision-making regarding length of stay of mothers and newborns after delivery. Furthermore, the AAFP endorses reimbursement of both professional and hospital costs for medically-indicated stays determined by the physician.32

Council on Scientific Affairs

The Council on Scientific Affairs has stated that in the absence of definitive empirical data, perinatal discharge of mothers and infants should be determined by the clinical judgment of attending physicians and not by economic considerations. This decision should be made based on the criteria of medical stability, delivery of adequate pre-discharge education, need for neonatal screening, and determination that adequate feeding is occurring. A plan should be in place for psychosocial and medical follow-up, as outlined in the Guidelines for Perinatal Care developed by the AAP and ACOG.13

Minnesota Policies/Standard of Care

The following are recommendations put forth by Minnesota health insurers regarding the timing of discharge following delivery.

HealthPartners

HealthPartners position statement on discharge states that hospital discharge following normal vaginal delivery is dependent on the medical and physical stability of the mother and her newborn infant; it is not dependent upon a prescribed length of hospital stay. Appendix III of this report identifies HealthPartners' criteria to be met and procedures to be followed when considering discharge within 24 to 36 hours after normal vaginal delivery.

Additionally, HealthPartners states that early discharge is only an option and that the final decision for each patient's length of stay is based on medical necessity and mutual agreement between the patient and her provider.33

Blue Cross Blue Shield of Minnesota

Blue Cross Blue Shield of Minnesota's (BCBSM) policy statement for postpartum stays states that the decision of the length of stay should be based on medical necessity and determined on a case-by-case basis. The decision for an appropriate discharge will be made collaboratively between the attending physician, facility, and the patient.

BCBSM will become involved in the decision if the length of stay exceeds 48 hours for a normal vaginal delivery and 96 hours for a cesarean section. The case will be reviewed for medical necessity using standard criteria.34

Medica

Medica provides discharge guidelines which are to be met prior to discharge following vaginal delivery. Medica discharge criteria are presented in Appendix III of this report.35

Outstanding Issues

Many issues related to early discharge of mother and infant have yet to be addressed in the literature. For this reason, the outstanding issues presented below are intended to identify those issues which should be considered in the early discharge debate but for which little information is currently available:

  • How is health plan coverage interpreted, translated, communicated, and applied in the delivery site (hospital)? There is an apparent disconnect between the discharge criteria of insurers and the actual practice of hospitals. The dialogue between payers and providers may clarify misunderstandings needs to be better understood on this issue.
  • Where should follow-up after discharge occur (hospital, clinic, home) and how does continuum of care throughout the postpartum period vary with the time of discharge?
  • How can fail-safe newborn screening take place when infants are discharged early?
  • Issues related to rural mothers and infants have not been addressed. For example, response time for medical emergencies after discharge from the hospital, the availability of technologies and resources in the rural community, and staffing costs in a rural hospital setting are all issues that would have an impact on discharge planning for rural mothers and newborns.
  • Is there a relationship between socio-economic status and post-delivery length of stay? This may be of special interest for post-discharge planning, in cases where there are fewer resources to assist the mother. The level of support that is available to women who depend upon economic assistance may not be adequate to address their needs. This issue needs to be studied in greater detail.
  • Patient satisfaction related to early discharge should be explored more thoroughly. What emphasis should be placed on the importance of patient preference?
  • Are there differences in maternal readmission rates after first versus subsequent births? We need a better understanding of who gets readmitted into the hospital.
  • The role of hospitals has changed over time. Previously, hospitals served many purposes (treatment, rest, observation, etc.). Currently, hospital stays are used for those requiring intensive evaluation or treatment. Should an intermediate setting for care and services be considered?
  • Appropriate education and follow up services (including screening) are also necessary for families who deliver outside the hospital setting (i.e. at home).
  • The economic ramifications of early discharge need to be addressed in a larger context so as to capture all relevant information.
  • Discharge planning for more complicated deliveries, such as cesarian section, should also thoroughly evaluate the individual needs of each mother and infant.

Conclusions

To date, data are inconclusive in demonstrating either a positive or negative correlation between optimal outcome of pregnancies and length of stay following delivery. Local and community-wide research to address many of the concerns related to timing of discharge are needed.

The birth of each child is unique, with a multitude of factors (e.g., physical status of mother and infant, availability of social support at home and in the community, resources within the hospital) affecting the outcome. To ensure optimal care for both mother and child, the time of discharge should be determined on an individual basis. Care systems need to develop appropriate programs to meet the unique needs of their patients within the context of their communities. Individualized discharge plans can and should be established through the utilization of medical assessment and community resource assessment.

Care is not adequately measured in terms of hours. The needs of each mother and baby must be assessed on an individual basis, and care delivered in a manner that makes the most sense for each unique birth situation. Therefore, a legislative mandate can not assure optimal care. Instead, we should focus on the continuum of care for the mother and baby, and emphasize the importance of establishing appropriate plans for the post-delivery care and stabilization of mother and newborn.

Guidelines for Infant Discharge

The guidelines put forth by the American Academy of Pediatrics(9) may serve as a basis for meeting the minimum discharge criteria. See below for specific discharge criteria recommendations:

  • The antepartum, intrapartum, and postpartum courses for both mother and baby are uncomplicated.
  • Delivery is vaginal.
  • The baby is a single birth at 38-42 weeks' gestation and the birth weight is appropriate for gestational age according to appropriate intrauterine growth curves.
  • The baby's vital signs are documented as being normal and stable for the 12 hours preceding discharge, including a respiratory rate below 60/min. a heart rate of 100 to 160 beats per minute, an axillary temperature of 36.10C to 37.0C in an open crib with appropriate clothing.
  • The baby has urinated and passes at least one stool.
  • The baby has completed at least two successful feedings, with documentation that the baby is able to coordinate sucking, swallowing, and breathing while feeding.
  • Physical examiantion reveals no abnormalities that require continued hospitalization.
  • There is no evidence of significant jaundice in the first 24 hours of life.
  • The mother's knowledge, ability, and confidence to provide adequate care for her baby are documented by the fact that she has received training sessions regarding the following issues:
    • Breast-feeding or bottle-feeding. The breast-feeding mother-infant dyad should be assessed by trained staff regarding nursing position, latch-on, adequacy of swallowing, and mother's knowledge of urine and stool frequency.
    • Cord, skin, and infant genital care.
    • Ability to recognize signs of illness and common infant problems, particularly jaundice.
    • Proper infant safety (e.g., proper use of a car seat and positioning for sleeping).
  • Family members or other support person(s), including health care providers, such as the family pediatrician or his/her designees, familiar with newborn care and knowledgeable about lactation and the recognition of jaundice and dehydration are available to the mother and the baby for the first few days after discharge.
  • Laboratory data are available and reviewed, including maternal syphilis and hepatitis B surface antigen status, cord or infant blood type and direct Coombs' test result as clinically indicated.
  • Screening tests are performed in accordance with state regulations. If the test is performed before 24 hours ofmilk feeding, a system for repeating the test must be assured during the follow-up visit.
  • Initial hepatitis B vaccine is administered or a scheduled appointment for its administration has been made within the first week of life.
  • A physician-directed source of continuing medical care for both the mother and the baby is identified. For newborns discharged in less than 48 hours after delivery, a definitive appointment has been made for the baby to be examined within 48 hours of discharge. The follow-up visit can take place in a home or clinic setting, as long as the personnel examining the infant are competent in newborn assessment and the results of the follow-up visit are reported to the infant's physician, or designees, on the day of the visit.
  • Family, environmental, and social risk factors should be assessed. These risk factors may include but are not limited to: 1) untreated parental substance abuse/positive uring toxicology results in the mother or newborn; 2)history of child abuse or neglect; 3) mental illness in a parent who is in the home; 4) lack of social support, particularly for single, first-time mothers; 5) no fixed home; 6) history of untreated domestic violence, particularly during this pregnancy; or 7) teen mother, particularly if other conditions above apply. When these or other risk factors are present, the discharge should be delayed until they are resolved or a plan to safeguard the infant is in place.

It is essential that all infants having a short hospital stay be examined by experienced health care providers within 48 hours of discharge. If this cannot be assured, then discharge should be deferred until a mechanism for follow-up evaluation is identified.

The purpose of the follow-up visit is to:

  • Assess the infant's general health, hydration, and degree of jaundice; identify any new problems; review feeding pattern and technique, including observation of breast-feeding for adequacy of position, latch-on, and swallowing; and assess historical evidence of adequate stool and urine patterns.
  • Assess quality of maternal-infant interaction and details of infant behavior.
  • Reinforce maternal or family education in infant care, particularly regarding infant feeding.
  • Review the outstanding results of laboratory tests performed before discharge.
  • Perform screening tests in accordance with state regulations and other tests that are clinically indicated.
  • Identify a plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screening.

In summary, the fact that a short hospital stay (<48 hours of age) for healthy term infants can be accomplished does not mean that it is appropriate for every mother and infant. Each mother/infant dyad should be evaluated individually to determine the optimal time of discharge.

Guidelines for Maternal Discharge

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have developed Guidelines for Perinatal Care;14 an excerpt related to care of the mother is shown below:

Upon discharge, the following points should be reviewed with the mother or, preferably, with both parents:

  • Condition of the neonate
  • Immediate needs of the neonate (e.g., feeding, methods and environmental supports)
  • Roles of the obstetrician, pediatrician, and other members of the health care team concerned with the continuous medical care of the mother and neonate.
  • Availability of support systems, including psychosocial support
  • Instructions to follow in the event of a complication or emergency
  • Feeding techniques, skin care, including cord care; temperature assessment and measurement with the thermometer; and assessment of neonatal well-being and recognition of illness
  • Reasonable expectations for the future
  • Importance of maintaining immunization begun with initial dose of hepatitis B vaccine

When the mother is discharged early, certain criteria should be met:

  • The mother should have an uncomplicated vaginal delivery following a normal antepartum course and should have been observed after delivery for a sufficient time to ensure that her condition is stable. Pertinent laboratory data, including a postpartum determination of hemoglobin or menatocrit level and, if not previously obtained, ABO blood group and Rh typing, should have been obtained. If indicated, the appropriate amount of RhIg should have been administered.
  • Family members and other support person(s) should be available to the mother for the first few days following discharge
  • The mother should be aware of possible complications and should have been instructed to notify the appropriate practitioner, as necessary
  • Procedures for readmission of obstetric patients should be consistent with hospital policy, as well as local and state regulations.

APPENDIX I: Glossary

The following definitions define terms as they pertain to this report. These definitions do not necessarily apply when these terms are used in specific citations from other sources.

Cost Effectiveness Analysis: A technique used to measure the relationship betweeen the cost of care and the benefit that is derived from it.

Early Discharge: Generally refers to a length of stay between one and two days after an uncomplicated vaginal delivery. A one day stay may be 13-35 hours, depending on when the mother delivers.

Length of Stay: The amount of time a mother and infant are hospitalized following delivery. This time does not include the time spent in the hospital preceding delivery.

Nosocomial Infection: Hospital-acquired infection; the source of infection is directly attributable to the hospital environment.

Postpartum: The period of time following the delivery of the infant, typically identified as 6 weeks following delivery. This report focuses on the portion of postpartum that relates to discharge time.

APPENDIX II: Summary of Reviewed Articles

The following is a tabulation of the articles reviewed thus far. Observations and summaries of the articles follow this table:

ReferenceSite/DesignNo. Of PatientsDischarge time post-deliveryFollow-up careResults
Carty, 1990Tertiary care maternity hospital in Vancouver.

Vaginal deliveries only. Random selection.
Grp.1: 44

Grp 2: 49

Grp.3: 38
Grp.1:

12-24 hrs.

Grp.2:

25-48 hrs.

Grp.3: 4 days

(traditional stay)
Nurse home visits:

Grp.1: day 1,2,3,4,5,10.

Grp.2: day 3,5,10.

Grp.3: day 10 only.
No differences found in patient health. ED reported more satisfaction and more confidence in mothering role.
Conrad, 1989Univ. Of Colorado School of Medicine.

Indigent population.

Retrospective analysis.
Grp.1: 1091

Grp.2: 343

Grp.3: 563
Grp.1: 24-36 hrs.

Grp.2: 36-48 hrs.

Grp.3: >48 hrs.
Mandatory out-patient visit within 48 hrs. Of discharge.Group 1 had more readmissions than group 3.
Arborelius, 1989Motala Hospital, Sweden.

Voluntary early discharge.
ED: 26

Ctrl: 22
ED: 0-2 days

Ctrl: 5-6 days
Daily home visits by midwife and/or nurse. Examination at hospital 6-7 days after birth.No difference regarding psychological factors or breast-feeding.
Pittard, 1988Medical Univ. Of South Carolina.

Retrospective analysis.

Economically diverse grp.
ED: 1714

Ctrl: 622
ED: 31+5 hrs.

Ctrl: 92+44 hrs.
Not mentioned.No difference in infant readmissions within 6 weeks of birth.
Thurston, 1985Large general hospital, Calgary. Voluntary participation.ED: 376

Ctrl: None
Within 48 hrs.Home visits on 3rd, 4th, 5th postpartum day.Hospital stay deemed appropriate by 86% of participants, too short by 7%, and too long by 7%.
Yanover, 1976Kaiser-Permanente Medical Center, San Francisco.

Random selection. Low risk patients.
ED: 44

Ctrl: 44
ED: 12-48 hrs. Ctrl: >48 hrs.Daily home visits through 4th postpartum day, additional visits as needed. Nurse available during first 2 weeks.No differences in number and types of morbidity for mothers or infants in first six weeks after delivery. The cost of providing the program was approximated by the immediate savings from early discharge.

Key: ED = Early Discharge group, Ctrl = control group

Observations from the Trials

Most reports published until now are either retrospective studies or studies done with voluntary early discharge, decided before delivery.

Britton3observes that most published reports have included only small groups of infants, and consequently sufficient statistical power is lacking. Because groups are small, a single additional readmission in either early or late discharge groups could, in many cases, affect the overall outcome of the study.

Assuming a minimum incidence of problems requiring re-admission in the population to be 1%, 38,211 infants would be needed in each group to detect a difference in outcome of 25%. It is unlikely that a study of this magnitude could be performed at a single center, and a multi center effort would be needed.3

Summary of Articles Reviewed

Carty, 1990

The study took place at a tertiary care maternity hospital in Vancouver. All women expecting a vaginal birth were eligible to participate. Women who agreed to be randomly assigned to one of three discharge times were visited at home by a project nurse at approximately 38 weeks' gestation who explained the study in greater detail, obtained written consent, and assigned time of discharge. The final sample consisted of 131 women. The discharge schedules were as follows:

  • Early discharge:
  • Group 1-12 to 24 hrs. (n=44) Group 2-25 to 48 hrs. (n=49)
  • Traditional stay:
  • Group 3-4 days (n=38).

Five project nurses made home visits to the women under their care according to the following schedules : group 1 on days 1, 2, 3, 5, and 10 after delivery; group 2 on days 3, 5, and 10; group 3 on day 10 only. At each visit the nurses provided similar nursing care to that received by women in hospital. They conducted a physical assessment of the mother and baby, dealt with the immediate concerns of the parents, assisted them with getting to know their baby, and dealt with the many facets of incorporating a new member into the family. Questionnaires were left with the participants to be completed at four time periods : 37 weeks' gestation, during hospital stay, 1 week postpartum, and 1 month postpartum.

Results: The demographic characteristics of the women in the three groups did not differ significantly after randomization. Over 95% of the women were Caucasian, 93% were married or living with their partner, 65% had completed junior college or university, and 58% had a combined family income over $40,000. Fifty-three percent were primiparas and 47% multiparas.

Maternal and infant health: Regardless of the time of discharge, the women experienced a generally healthy postpartum course. The frequency of maternal problems requiring physician referral in the first 10 days postpartum was 5.3% (n=5) in the early discharge groups and 7.9% (n=3) in the traditional stay group. One instance of each problem was reported, by group, as follows : group 1 - urinary tract infection and episiotomy infection; group 2 - mastitis, episiotomy infection, and subinvolution; and group 3 - endometritis, episiotomy infection, and subinvolution. Of women referred to a physician, two (1.5%0 were hospitalized within the first month postpartum : one from the earliest discharge group for a urinary tract infection, and the other, from the traditional stay group for endometritis.

During the first 10 days postpartum, the frequency of problems in infants requiring physician referral was 4.3% in groups 1 and 2, and 2.6% in group 3. Reasons were hyperbilirubunemia, cord infection, ABO incompatibility, diaper rash, and respiratory difficulties.

Breast-feeding: On discharge from hospital, 98% of all women in the study were breast-feeding. At one month, 87% of the women in the early discharge groups and 79% in the traditional group were giving their babies breast milk only. The one-month questionnaires were returned by mail with a rate of return of 75%.

Psychological functioning: The responses of the women in the three groups did not differ significantly with respect to levels of trait anxiety, or state anxiety assessed prenatally, in hospital at one week, or at one month postpartum.

Women in the three groups did not differ on their prenatal scores on the Beck Depression Index. Those who stayed in hospital for 4 days scored significantly higher on that index at the 1-month follow-up (P<0.05) than did women who were discharged 12 to 24 hours postpartum.

At one week, women who were discharged within 24 hours scored significantly higher than those in the two other groups on the subscale assessing confidence regarding the mothering role (P<0.03). There were no significant differences among the groups with respect to scores on this subscale completed at one month postpartum. This finding suggests that women who have complete responsibility for their baby earlier feel more confident initially than those who do not. It could also mean that the nursing visits enhanced women's feelings of confidence regarding their mothering role.

Patient satisfaction: All the women were satisfied with their care, as demonstrated by their responses on the patient satisfaction questionnaire. However, women who were discharged earliest reported being significantly more satisfied than those discharged later (P<0.0009) they were also significantly more satisfied with nursing care.

In summary, this study shows favorable results for early discharge. However, it is appropriate to point out that since participants were healthy, well-educated women and living in a stable relationship with their husbands or partners, the findings cannot be generalized to a high-risk population. Moreover, since participation was voluntary, it studied only a particular type of woman, who is willing to experience postpartum care that ranges from going home within 12 to 24 hours after birth to a hospital stay of 4 days. As for satisfaction, since the nurses providing home visits were specially chosen, one can only conjecture that some of the findings related to satisfaction, depression, and confidence in the mothering role might have been different if the study nurses had also provided in-hospital care for group 3.

Conrad, 1989

This is a retrospective review of newborn hospital and outpatient medical record of 2000 consecutively born infants admitted into the transitional nursery for level I care at University of Colorado Health Sciences Center, Denver. Infants who initially required a higher intensity of care (i.e., direct admissions in level II or III nursery units) were excluded from this study. The data collected included the following : sex, estational age, birth weight, length of hospital stay, neonatal complications, need to transfer into level II or III units, reason for the hospital stay to exceed 36 hours, documentation of outpatient follow-up within 48 hours of initial discharge, and readmission to the hospital within seven days of initial discharge.

Results: Review of the financial status of mothers demonstrated that 77% were in a lower income bracket (23% were eligible for Medicaid assistance, and the remaining 54% had an average income for a family of four <$17,000 per year). The maternal age in this group was 23.2+5.1 years.

The newborn medical records from the 2000 infants born during the study period were divided into three groups. Group 1 consisted of infants discharged within 24 to 36 hours of birth (n=1091), group 2 infants were discharged 36 to 48 hours after birth (n=343), and group 3 infants were discharged more than 48 hours after birth (n=563). Although no significant differences in birth weight and gestational age were found among any of the discharge groups, there was a trend in group 3 toward greater numbers of infants of 37 weeks' gestation or less and 42 weeks' gestation or longer, as well as greater numbers of infants small or large for gestational age.

The reasons hospital stay exceeded 36 hours for group 2 and 3 infants included:

  • Maternal problems that included recovery from cesarean section, postpartum tubal ligation, and recovery from pregnancy-induced hypertension and genital injuries (lacerations and contusions of the maternal genitalia).
  • Infant problems - low birth weight was the most frequent neonatal cause for the newborn hospitalization to exceed 36 hours (10.3%). The 51 infants who stayed for social reasons included all infants born to mothers with psychiatric disease and substance abuse.

All infants in group 1 had a mandatory outpatient follow-up visit within 48 hours of discharge. Successful visits were accomplished in 91.1% of the cases. Reasons for the 8.9% unsuccessful visits were : no documentation 3.8%, could not locate 4.1%, refused by parent 0.6%, child adopted 0.3%.

The overall readmission rate for the entire population studied was 1.8%. Significantly greater numbers of readmissions came from infants in group 1 (2.3%) than from group 3 (0.895, P<.05). Treatment of jaundice with phototherapy was the most frequent cause for readmission, 65% of these came from group 1. The second most common reason for readmission was physical signs suggesting bacteremia or viremia.

The authors comment that illiteracy, young maternal age, lack of transportation, and inability to defray the cost of prenatal care may serve to limit prenatal child care education and medical care for women in lower socioeconomic groups. Single-parent status may limit support at home. Provision of health care through several ambulatory systems as well as frequent household moves and a lack of telephone service compromise the establishment of optimal follow-up in the postpartum period. These problems could serve to limit the applicability of early newborn discharge, as outlined by the AAP and ACOG, to large segments of the population that otherwise meet the medical criteria.

Arborelius, 1989

This study was carried out from October 1984 to September 1985 in Motala Hospital, Motala, Sweden. Early discharge was a voluntary alternative for subjects of this study. All pregnant women living in the central parts of Motala were informed by their midwives at the end of the pregnancy. They were told that no decision had to be made before the delivery, and that they could return to the hospital if things did not work out.

Early discharge was defined as hospital stay of 0-2 days after birth, and late discharge as 5-6 days after birth. The families who chose early discharge got daily home visits by a midwife and/or a pediatric nurse. The patients were also free to call the hospital at any time. At the hospital a pediatric examination of the child was done 6-7 days after birth; if necessary an obstetrical examination of the mother was also done.

Altogether 44 women (7 primiparae and 37 multiparae) participated in this study, 22 in the early discharge group and 22 in the controls. There were no differences between the early discharge group and the control group regarding demographic variables such as age, living conditions, education, social class, marital status and nationality. The fathers were also interviewed. There were no differences between the groups regarding the number of days the fathers had been at home during the first month after birth.

Results: Both the early discharge group and the control group were very satisfied with their choice of length of stay.

Breast-feeding: A full month after birth 18/22 mothers in the early discharge group were breast-feeding and 21/22 in the control group. Half a year after birth the corresponding numbers were 12/19 and 14/19. The differences were not significant.

Pittard, 1988

This study is a review of the hospital charts for all infants admitted to the well-baby nursery is the Medical University of South Carolina between January 1 and December 31, 1985. Because of the need for obstetric beds, the practice at the MUSC was to discharge newborn infants after 24 hours but before 48 hours after delivery. To assess neonatal well-being after this moderately early discharge, the number of infants readmitted to the hospital within 6 weeks of birth was evaluated.

The early discharge group comprised 1714 infants who had no maternal or newborn clinical problem identified within the first 24 hours of life. These neonates remained in the hospital for 31 + 5 hours after delivery. The 622 infants in the control group were those who had no neonatal problems identified during the first 24 hours of life and were assigned to an extended hospitalization (92 + 44 hours) solely as a result of maternal concerns. All neonates with extended hospitalization because of neonatal problems were not included in the study.

Results: Of the 1714 babies discharged moderately early, 52 (3.0%) were readmitted within 6 weeks of birth. Of the 622 control cohort infants, 17 (2.7%) were readmitted by 6 weeks of age. Of the 69 total readmissions, 50 (72%) resulted from suspected infectious disease. Six infants had sepsis, with blood or spinal fluid cultures positive for bacterial growth. Five infants were readmitted for jaundice in the first week after discharge. None of these infants required an exchange transfusion, and the serum bilirubin concentration declined with phototherapy in each case.

Of the total study population, 3.3% of the indigent, 3.1% of the Medicaid babies, and 1.5% of the private service babies were readmitted within 6 weeks of birth. Of the babies delivered by cesarean section 2.7% were readmitted by age 6 weeks. This incidence did not differ significantly from the readmission incidence of either the remaining control infants or the experimental infant group.

Of the infants discharged moderately early, 2.6% of black infants and 4.0% of white infants were readmitted within 6 weeks of birth. These rates did not differ significantly from each other, nor from the readmission rates among the extended hospitalization group.

In conclusion, therefore, suspected infectious disease was overwhelmingly the major cause for readmission; hyperbilirubinemia was rare. Maternal age, race, and parental financial status were not predictors of early infant readmission.

Thurston, 1985

This is an evaluation of safety and satisfaction of patients discharged early after delivery. Participation in the early discharge program by both mothers and physicians was voluntary. Discharge was proposed within 48 hours postpartum.

Mothers electing early discharge were assessed by their physicians for suitability. Routine home visits were made on the third, fourth and fifth postpartum days by a select group of specially trained Community Health Nurses who had received additional recent theoretical content and clinical experience in obstetrics. This was followed by a further at about two or three weeks post delivery, a visit which was already being made to all new mothers. Nurses followed established protocol on each of these visits, providing routine patient care, postnatal teaching, and assessment of the physical and emotional status of the mother and physical condition of the baby. A total of 376 women participated in this program.

Results: A high percentage of mothers (78%) breast fed their babies at discharge from the hospital and 75% had continued breast-feeding at five days postpartum. Nursing records indicated maternal problems were most commonly related to perineal bruising, discomfort and hemorrhoids or to breast related symptoms. For babies, the most frequently noted problems were associated with a “jaundiced” coloring or to difficulties with skin care such as diaper rash.

Three mothers and three babies had developed a more serious complication during the first few weeks post delivery. Two infants were discharged with bilirubin readings on the second day exceeding that stated in the criteria, and, for one baby, it is unclear whether discharge occurred before the level was known. Both were readmitted to hospital with high bilirubin levels, and were treated with phototherapy. Another baby was seen and readmitted for respiratory illness at 32 days after discharge.

Two mothers had late postpartum hemorrhages owing to retained placenta and were readmitted for dilation and curettage.

The hospital stay was deemed appropriate in length by 86% of respondents, too short by 7%, and too long by the remaining 7%. Altogether, 97% of participants would suggest the program to friends, and 93% would participate again. Reasons cited were that the program was basically good, that they were more relaxed at home, that bonding improved, and that a home support system was available to them. Only 5% of patients would not participate again, stating that they required more rest, additional help at home, or did not want early discharge.

Yanover, 1976

A total of 88 low-risk patients were randomly assigned to either the early discharge group (n = 44) or control group (n = 44), at Kaiser-Permanente Medical Center, San Francisco. There were no statistically significant differences between the to groups in age, race, father's occupation, planned pregnancy, duration of marriage, length of time to conceive, mother's and father's education, presence of another child in the home, or mother's preference regarding enrollment in prenatal education classes, natural childbirth, or breast-feeding.

Patients in the control group were discharged not earlier than 48 hours with a pediatric visit at two weeks, and obstetric visit at six weeks. Patients in the study group stayed for 12-24 hours postpartum, and the perinatal nurse practitioner made daily home visits for health surveillance and teaching of parent craft through the fourth postpartum day, with additional visits as needed. The perinatal nurse practitioner who was assigned to a family was available to that family during the first two weeks postpartum.

Results: No significant differences or trends were observed in the numbers and types of morbidity occurring during hospitalization or during the first six weeks after delivery in mothers or infants of the study and control groups. The 13 cases of infant morbidity are:

Type of MorbidityNumber of Cases
STUDYCONTROL
Apgar score < 7 at 5 min.02
Total bilirubin > 15 mg/dl22
Superficial skin infections23
Pneumonia
  Aspiration01
  Intrauterine01
Total49

The mothers' complications included precipitous or prolonged labor, midforceps delivery, obstetric laceration, postpartum infection, and postpartum hemorrhage.

The authors estimate that the cost of providing the program's services was approximated by the immediate saving derived from early discharge.

APPENDIX III: Health Plan Policies

HealthPartners

In its position statement for maternity lengths of stay, HealthPartners outlines the following criteria for discharge occurring within 24-36 hours of delivery:33

  1. Maternal Criteria
    1. Vaginal term delivery without extensive lacerations or tears
    2. Absence of postpartum hemorrhage
    3. Afebrile and other vital signs within patient's normal limits
    4. Ambulatory without assistance
    5. Voiding without difficulty and in sufficient amounts
    6. Tolerating fluids or light diet
    7. Review and documentation of maternal knowledge and comfort level regarding the following:
      (1)Self care including perineal care, breast care, use of medications
      (2)Infant care including feeding, handling/positioning, normal newborn behavior, cord care, circumcision care (if applicable)
    8. Adequate support available in home setting
    9. Absence of medical contraindications to discharge and mother is physically and psychologically/emotionally ready for discharge
  2. Newborn Criteria
    1. Gestational age at least 36 weeks
    2. Birth weight at least 2500 grams
    3. Vital signs stable
    4. Normal glucose or chemstrip
    5. Routine newborn screening done
    6. Tolerated at least two feedings
    7. Newborn exam by family practitioner, pediatrician, or pediatric nurse practitioner supports plan for discharge.
  3. Other Factors for Consideration (List includes but is not limited to the following):
    1. Assessment of emotional, behavioral, psychological and/or social issues
    2. Indications of substance abuse
    3. Previous perinatal loss
    4. Maternal fatigue or exhaustion
    5. Multiple gestation

Discharge Procedures

  1. Mother and, if possible, her support person are informed of abnormal signs or symptoms to watch for in the first several days following discharge and given written instructions on how to receive assistance if questions or emergencies arise.
  2. A home or office visit to assess newborn status is scheduled within 2 to 5 days following discharge. If the patient declines, cancels, or fails the visit, a phone call is made within this time frame to ascertain the well-being of both mother and infant.
  3. Routine pediatric (well child) care commences within 2 weeks and a postpartum visit is scheduled within 4 to 8 weeks.

Expectations

  1. Expectations of hospitals:
    1. Policies, procedures and or protocols are in place to support appropriate postpartum monitoring and assessment.
    2. Review and reassurance are provided for safe transition of care to home.
  2. Expectations of obstetric providers:
    1. Facilitate the inclusion of newborn care into prenatal education.
    2. Discharge planning is initiated prior to hospitalization
    3. Timing of discharge is coordinated with assessments of maternal medical and physical stability, newborn status, and patient concurrence.
  3. Expectations of practitioners who provide newborn care:
    1. Provision of appropriate home nursing visits or office visit within 2 days of discharge.
    2. Office or phone availability for questions by either home nurse or parents.
  4. Expectations of HealthPartners:
    1. Ongoing monitoring of patient outcomes and satisfaction.
  5. Expectations of patients:
    1. Assume an active role in planning for the birth process and the transition of care from hospital to home.
    2. Identify the practitioner selected to provide newborn care prior to hospitalization.

Blue Cross Blue Shield of Minnesota

Blue Cross Blue Shield of Minnesota's (BCBSM) policy statement for postpartum stays states that the decision of the length of stay should be based on medical necessity and determined on a case-by-case basis. The decision for an appropriate discharge will be made collaboratively between the attending physician, facility, and the patient.

BCBSM will become involved in the decision if the length of stay exceeds 48 hours for a normal vaginal delivery and 96 hours for a cesarean section. The case will be reviewed for medical necessity using standard criteria.34

Medica

The following discharge guidelines as put forth by Medica have been adapted from discharge guidelines developed by the Perinatal Community Consortium. These guidelines have been approved by the OB/GYN, Family Practice and Pediatrics Advisory Committees.35

Discharge Criteria (*Starred items represent criteria that when unmet may require a longer inpatient stay, even if all other criteria are met.)

  1. Physiological
    1. Mother
      1. Afebrile
      2. No evidence of chorioamnionitis
      3. *Blood loss < 700 cc
      4. *Labor < 24 hours
      5. Blood pressure stable
      6. Fundus firm
      7. Absence of tenderness in calves
      8. Lochia - saturating < 1 pad / 2 hours
      9. Voiding without difficulty
      10. Ambulating without assistance
      11. RH status determined and RhoGam given, if appropriate
      12. If necessary, hepatitis status determined and the patient is available for follow-up
      13. Rubella status determined and rubella immunization repeated, if appropriate
      14. Hemoglobin checked
      15. Evidence that pre-eclampsia is resolving, if present
      16. Pain control is adequate to allow mother to care for baby
    2. Infant
      1. *Apgar 7 or greater at 5 minutes
      2. *Gestational age 37-42 weeks
      3. *Birth weight 6 lbs-9 lbs. 5 oz (2700-4300 grams)
      4. Vital signs:
        1. temp. 98.6-100.4 F (rectally or equivalent)
        2. heart rate 90-150
        3. respiratory rate 30-60
      5. Must have voided prior to discharge
      6. Must have had a bowel movement prior to discharge
      7. Sucking and feeding must have observed ability to suck and swallow prior to discharge
      8. *Physical exam normal
      9. Blood tests
        1. Metabolic screening-per state law, metabolic screening must be done prior to the fifth day after birth. If done prior to 24 hours after birth, the parents or legal guardian must be notified of the need to have it retested before the 14th day after birth.
        2. Baby's blood type determined and noted on the cord blood sample
      10. Circumcision (may be performed after discharge, if wanted)
      11. Baby discharge weight appropriate
      12. Safe environment for the baby
  1. Psycho-Social
    1. Support system:
      1. transportation must be available
      2. a responsible party is available to assist the mother in an emergency
      3. basic physical supplies for the infant must be present
      4. housing with heat and sanitation facilities
      5. an emergency plan is in place if a phone is not available
    2. Relationship between mother and infant:
      1. absence of hostile/negative comments toward the infant
      2. mother holds baby face to face
      3. interaction between the mother and baby is present
  1. Under these circumstances mothers and babies may require inpatient days in excess of those indicated by medical criteria. While additional inpatient days do not change these circumstances, they may be necessary to make special arrangements.
    1. Prenatal care not initiated by 28 weeks gestation or characterized by frequent missed appointments
    2. Presence of the following:
      1. history of severe postpartum or other depression (consider when the depression was not previously addressed with counseling, etc.)
      2. current medical illness
      3. battering during this pregnancy
      4. drug and/or substance abuse during the pregnancy
    3. Patient is younger than 16 years
    4. Depressed affect

Notes:

  1. Discharge teaching should begin during the perinatal period, and continue throughout the intrapartum period. Postpartum instructions may be given in the home.
  2. Every patient, discharged in 24 hours or less, should have home care visits routinely, unless the provider determines that these visits are not necessary.
  3. The birth certificate should be issued per the institution's policy.
  4. If baby's condition requires continued hospitalization, this in itself does not constitute medical necessity for continued hospitalization of the mother. A place in close proximity to the hospital, however, must be available to the mother to facilitate successful establishment of feeding and bonding.
  5. When the practitioner makes a determination that a patient meeting these criteria is not ready to be discharged (e.g.., patient still exhausted from delivery, home issues, etc.), the reason for continued inpatient stay should be documented in the chart.

APPENDIX IV: Minnesota Statistics

Infant, Neonatal, and Postneonatal Deaths by Cause: Minnesota Residents, 1994(36)

Cause of DeathInfant DeathsTotalUnder 1 day1-6 days7-27 daysPost-Neonatal
Total - all causes4512961895750155
Infective and Parasitic Diseases

Septicemia
6

1
1

-
-

-
-

-
1

-
5

1
Neoplasms

Malignant Neoplasms
2

1
-

-
-

-
-

-
-

-
1

1
Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders42-112
Diseases of the Blood and Blood-Forming Organs1----1
Mental Disorders------
Diseases of the Nervous System and Sense Organs71--16
Diseases of the Circulatory System1072323
Diseases of the Respiratory System

Pneumonia and Influenza
13

8
1

-
-

-
-

-
1

-
12

8
Diseases of the Digestive System521-11
Diseases of the Genitourinary System21-1-1
Diseases of the Skin and Subcutaneous Tissue------
Diseases of the Musculoskeletal System------
Congenital Anomalies

Anencephalus

Of Heart

Of Respiratory System

Of Urinary System

Chromosomal Anomalies
115

7

32

13

11

27
88

7

20

12

11

22
51

7

2

9

11

14
20

-

9

2

-

4
17

-

9

1

-

4
27

-

12

1

-

5
Certain Conditions Originating in the Perinatal Period

Maternal Conditions

Short Gestation and Low Birthweight

Birth Trauma

Intrauterine Hypoxia & Birth Asphyxia

Respiratory Distress Syndrome

Other Respiratory Conditions of Fetus and Newborn

Fetal and Neonatal Hemorrhage
194

65

40

9

4

11

34

1
186

65

40

8

3

10

31

1
133

59

38

-

1

3

20

1
31

2

2

5

2

6

6

-
22

4

-

3

-

1

5

-
8

-

-

1

1

1

3

-
Symptoms, Signs and Ill-Defined Conditions

Sudden Infant Death Syndrome
78

74
4

3
1

1
1

-
2

2
74

71
Unintentional Injuries

Motor Vehicles

Mechanical Suffocation
9

2

5
2

-

2
-

-

-
-

-

-
2

-2
7

2

3
Homicide1----1
Injury Undetermined Whether Accidently or Purposely Inflicted4----4

APPENDIX V:Minnesota Statutes 199662a.0411 Maternity Care

Every health plan as defined in section 62Q.01 subdivision 3, that provides maternity benefits must, consistent with other coinsurance, copayment, deductible, and related contract terms, provide coverage of a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarean section for a mother and her newborn.

The health plan shall not provide any compensation or other nonmedical remuneration to encourage a mother and newborn to leave inpatient care before the duration minimums specified in this section. The health plan must also provide coverage for postdelivery care to a mother and her newborn if the duration of inpatient care is less than the minimums provided in this section.

Postdelivery care consists of a minimum of one home visit by a registered nurse. Services provided by the registered nurse include, but are not limited to, parent education, assistance and training in breast and bottle feeding, and conducting any necessary and appropriate clinical tests. The home visit must be conducted within four days following the discharge of the mother and her child.

HIST: 1996 c 335 s 1

Copyright 1996 by the Office of Revisor of Statutes, State of Minnesota.

APPENDIX VI:Public Comments on Preliminary Report

A preliminary version of this report was released for public comment on February 5, 1996. Comments received were reviewed and may have resulted in additions, revisions or deletions to the report. Therefore, the page and paragraph numbers referenced in the following written comments may not coincide with the page numbers in this final report.

APPENDIX VII:Public Testimony Taken by the Minnesota Health CareCommissionon March 20, 1996, Regarding HTAC's FinalTechnology Evaluation Report

No public testimony was offered to the Minnesota Health Care Commission regarding this report.

Following the presentation and discussion of Post-delivery Care and Stabilization of Mother and Newborn, the Commission recommended a number of changes. The report was approved in its present version by the Commission on April 17, 1996.

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2.
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Britton, JR Early discharge of the term newborn: a continued dilemma. Pediatrics. 1994;94:291–295. [PubMed: 8065852]
4.
Campbell, IE Early postpartum discharge - an alternative to traditional hospital care. Midwifery. 1992;8:132–142. [PubMed: 1453980]
5.
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American College of Nurse-Midwives Position Statement Safeguarding maternal and infant health in a competitive health care environment. July 1995.
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Jansson, P Early postpartum discharge. Am J Nursing. 1985;85:547–550. [PubMed: 3846423]
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Conrad, PD, et al Safety of newborn discharge in less than in 36 hours in an indigent population. AJDC. 1989;143:98–101. [PubMed: 2910053]
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Pittard, WB and Geddes, KM Newborn hospitalization: a closer look. J Pediatrics. 1988;112:257–261. [PubMed: 3339506]
13.
Report 5 of the Council on Scientific Affairs (A-95). Impact of 24-hour postpartum stay on infant and maternal health.
14.
Guidelines for perinatal care, 3rd edition. Elk Grove Village: IL: American Academy of Pediatrics. 1992.
15.
Tests of infants for inborn involved in newborn metabolic screening program. 1994.
16.
Statement of decreasing length of hospital stay following delivery. May 23, 1995.
17.
Carty, EM, Bradley, CF A randomized, controlled evaluation of early postpartum hospital discharge. Birth. 1990;17:199–204. [PubMed: 2285437]
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Thurston, NE, et al Evaluation of an early post partum discharge program. Canadian J Pub Health. 1985;76:384–387. [PubMed: 4092180]
19.
Welt, SI, Cole, JS, Myers, MS, et. al Feasibility of postpartum rapid hospital discharge: a study from a community hospital population. Am J Perinatol. September 1993;10(5):384–7. [PubMed: 8240600]
20.
Waldenstrom, U Early discharge as voluntary and involuntary alternatives to a longer postpartum stay in hospital - effects on mothers' experiences and breast-feeding. Midwifery. 1989;5:189–196. [PubMed: 2615666]
21.
Beck, CT, Reynolds, MA, Rutowski, P Maternity blues and postpartum depression. JOGNN. 1992;21:287–293. [PubMed: 1494971]
22.
Romito, P., Zaleteo, C Social history of a research project: a study on early postpartum discharge. Soc Sci Med. 1992;34:227–235. [PubMed: 1557664]
23.
Schwartz, RM Short stay hospitalization for mother and newborns: concerns and issues. submitted to Maternal and Child Health Bureau. Providence: RI: The National Perinatal Information Center. November 1994.
24.
Harrison, LL Patient education in early postpartum discharge programs. MCN. 1990;15:–. [PubMed: 2153889]
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Seal, K Maternity mayhem. Maternity. 1995
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Yanover, MJ; Jones, D; Miller, MD Perinatal care of low-risk mothers and infants. N. Engl. J. Med. 1976;294:702–705. [PubMed: 1250282]
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Gonzalves, P; Hardin, JJ Coordinated care early discharge of postpartum patients at Irwin Army Community Hospital. Military Med. 1993;158:820–822. [PubMed: 8108027]
28.
November, 1995.
29.
AMANET. September, 1995
30.
November, 1995.
31.
American Academy of Family Physicians Position Statement. September 1995.
32.
Health Partners Position Statement: maternity lengths of stay. November, 1995.
33.
Blue Cross Blue Shield of Minnesota: policy for post partum stays. December, 1995.
34.
Medica Medical Policy for Vaginal Delivery: discharge criteria. September, 1994.
35.
Minnesota Health Statistics 1994. January 1996.

Approved by the Minnesota Health Care Commission April 17, 1996

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