Better care and better teaching
New model of postpartum care for early discharge programs
Mark J. Yaffe, MD, MCLSC, CCFP, FCFP Balbina Russillo, MD, CCFP Carol Hyland, BSCN Lajos Kovacs, MD, CM, FRCPC, FAAP Elaine McAlister, BSCN, MSC(A)
ABSTRACT
PROBLEM BEING ADDRESSED Rapid postpartum discharge has reduced opportunities to detect early newborn or parenting problems and to teach neonatal assessment and maternal postpartum care to medical trainees.
OBJECTIVE OF PROGRAM Development of a program to not only ensure adequate care of mothers and newborns after early hospital discharge, but also to teach outpatient assessment skills to family medicine residents.
MAIN COMPONENTS OF PROGRAM In an urban, secondary care, university-affiliated teaching hospital predominantly training family medicine residents, an interdisciplinary committee created and supervised a neonatal and maternal postpartum assessment program. Newborn infants and their mothers are seen by a family physician, a family medicine resident, and a nurse within 48 hours of discharge, after which care is assumed in the community by the child’s primary care physician. An assessment protocol developed by the interdisciplinary group promotes standardized mother and child care and a structured learning experience for trainees.
CONCLUSION Rapid follow up of early discharged infants and their mothers can be facilitated by a program of standardized assessment by a roster of pooled, interacting family physicians and nurses. When this assessment occurs in a teaching milieu, a comprehensive learning experience can be combined with defined objectives that emphasize and encourage newborn and maternal assessment for ambulatory patients.
RÉSUMÉ
PROBLÈME À RÉGLER Le congé rapide de l’hôpital après l’accouchement a réduit les possibilités de détecter tôt les problèmes chez le nourrisson ou dans le parentage, et d’enseigner l’évaluation néonatale et les soins maternels périnatals aux stagiaires en médecine.
OBJECTIF DU PROGRAMME L’élaboration d’un programme assurant non seulement des soins appropriés à la mère et au nouveau-né après le départ rapide de l’hôpital, mais aussi l’enseignement aux résidents en médecine familiale des compétences en évaluation en contexte ambulatoire.
PRINCIPALES COMPOSANTES DU PROGRAMME Dans un hôpital de soins secondaires et d’enseignement affilié à une université en milieu urbain, un comité interdisciplinaire a créé et supervisé un programme d’évaluation néonatale et maternelle après l’accouchement. Les nouveau-nés et leur mère sont vus par un médecin de famille, un résident en médecine familiale et une infirmière dans les 48 heures suivant le congé, à la suite de quoi les soins sont dispensés dans la communauté par le médecin de première ligne de l’enfant.
Un protocole d’évaluation conçu par le comité interdisciplinaire favorise des soins uniformes à la mère et à l’enfant et une expérience d’apprentissage structurée pour les résidents.
CONCLUSION On peut faciliter un suivi sans délai des nouveau-nés et de leur mère qui ont reçu rapidement leur congé de l’hôpital par un programme d’évaluation normalisée effectuée par une équipe regroupant des médecins de famille et des infirmières en interaction. Lorsque cette évaluation se produit en milieu d’enseignement, une expérience d’apprentissage complète peut être combinée à des objectifs définis qui ciblent et encouragent l’évaluation néonatale et maternelle en milieu ambulatoire.
This article has been peer reviewed.
Cet article a fait l’objet d’une évaluation externe.
Can Fam Physician 2001;47:2027-2033.
T
he last few decades have seen a trend toward shorter hospital stays for obstetric patients.1-3 Better understanding of the peri- natal process, changing maternal attitudes and preferences, and need for health care cost contain- ment gradually reduced 10-day admissions to 4 days for vaginal delivery and to 7 days for cesarean section.Today hospitals often discharge postpartum patients with uncomplicated cases within 48 hours.
These changes have necessitated standards delin- eating how newborn infants are to be assessed in the critical postpartum period. The American Academy of Pediatrics, the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada recommend that all neonates staying less than 48 hours be examined by experienced health care providers within 48 hours of discharge. If examination is impos- sible, discharge should be deferred to permit ongoing observation until follow-up care in the community is guaranteed.4,5 To ensure adequate continuing care for newborns and mothers, some advocates in Canada called for the creation of new interdisciplinary programs in which family physicians would have a vital role.3
Hospital nurseries have traditionally been the locale for teaching postpartum newborn and maternal assess- ment and care to medical trainees. A North American survey of postgraduate training programs has indi- cated, however, that the hospital environment and a lack of faculty time have minimized attainment of teaching goals in normal newborn care, that trainees are not universally taught about breastfeeding, and that generalists are insufficiently involved in develop- ment and implementation of curricula on newborn teaching.6 Anecdotal reports suggest early postpar- tum discharge results in fewer hospitalized newborns for teaching purposes, fewer opportunities for house staff to observe neonatal physiologic changes or ill- ness presentations, and fewer chances to observe early parenting and infant feeding.
Effectively training house staff in an era of short- stay hospitalizations has been reported to be difficult for a tertiary care short-stay pediatric unit,7 for a psy- chiatric inpatient unit,8 and for an internal medicine clinic serving patients who have been discharged from hospital.9 Nothing appears to have been published about what is possible for postpartum newborn and maternal assessment after early discharge. An optimal approach should incorporate a practical family physi- cian service model,3 should involve patient or family education, and should allow for innovative house staff teaching. This paper will describe development and operation of a program that fulfils these criteria.
Program description
Program infrastructure. St Mary’s Hospital Centre is an urban, secondary care, McGill University–
affiliated teaching hospital serving a diverse multi- cultural community. At the time our program was implemented, obstetricians and family physicians deliv- ered just under 4000 babies yearly. A large 2-year fam- ily medicine residency program trains between 35 and 45 residents annually.
Planning, implementation, and ongoing functional accountability for a comprehensive postpartum follow-up program was assigned to an interdisci- plinary committee with representatives from the hospital departments of Obstetrics and Gynecology, Pediatrics and Neonatology, Nursing, and Family Medicine. In the absence of new funding to support the program, shared physical space was allocated within the clinical and teaching Family Medicine Centre located in a hospital ambulatory services building. Seven family physicians and five nurses with interest in maternal and child health restruc- tured their existing activities on a rotating, pooled basis, aided by existing clinic support staff. Proximity to the main hospital building facilitated laboratory investigations, if indicated (eg, complete blood counts, electrolyte assessments, or serum bilirubin examination following abnormal photometry screen- ing for bilirubin). Re-admission of mothers or new- borns could similarly be expedited.
Operational criteria. The interdisciplinary commit- tee developed guidelines to support patient care and house staff teaching objectives.
• All neonates and mothers discharged within 48 hours of delivery should have follow-up appointments, optimally within 48 hours, with infants’ family phy- sicians or pediatricians. If appointments were impos- sible, an appointment in the postpartum assessment Dr Yaffe is an Associate Professor of Family Medicine,
Dr Russillo is an Assistant Professor of Family Medicine, and Dr Kovacs is an Assistant Professor of Pediatrics, all at McGill University in Montreal, Que. Dr Yaffe is Chief of the Department of Family Medicine, Dr Russillo is Coordinator of the Post-Partum Care Program, and Ms Hyland was Charge Nurse at the Family Medicine Centre at the time this article was written; Dr Kovacs is Director of Neonatology in the Department of Pediatrics, and Ms McAlister was Assistant Director of the
Department of Nursing at the time this article was written, all at St Mary’s Hospital in Montreal.
program would be booked for mother and baby by a hospital secretary at time of discharge.
• A roster of family physicians and nurses would ensure continuous staffing for postpartum care, sup- ported by on-call rotations of consulting pediatri- cians and consulting obstetricians for exceptional problems.
• Standards of care would be promoted by periodic, evidence-based, interdisciplinary sessions (eg, pre- dictive value of photometry bilirubin readings for various skin pigmentations).
• Health care forms (Tables 1 and 2) would be cre- ated to standardize records of history taking and physical examination, content of anticipatory or Table 1.Nurses’ neonatal and maternal assessment
INFANT DEVELOPMENT AND CARE
• Infant bathing
• Cord care
• Circumcision issues and care
• Elimination or diapering
• Rectal temperature
• Developmental milestones SECURITY
• Outings
• Chemical substances
• Environmental dangers NUTRITION
• Breast versus bottle
• Observation of feeding
• Frequency of feeding
• Maternal nutrition
• Breast care SUPPORT SYSTEMS
• Family dynamics
• Bonding behaviour
• Medical, nursing, and social networks MATERNAL CONCERNS
• Pain management
• Emotional status
• Other symptoms
Table 2.Physician assessment
DEMOGRAPHICS
Identification of family members present Language spoken
Date of birth
Name of delivering physician
Name of family physician or pediatrician PERINATAL HISTORY
Problems in pregnancy
Maternal age, gravida, para, abortion numbers Gestation age at birth
Fetal presentation
Spontaneous birth versus induction
Vaginal birth, cesarean section, forceps, suction, episiotomy Perineal tear (degree)
Group B streptococcus status Apgar score (1 and 5 minutes)
Frequency of bowel movements, urination, feedings NEWBORN EXAMINATION
Measurements
• Weights (birth, discharge, current)
• Length, head circumference Vital signs, appearance Full-body examination
• Fontanelles, head, fundi, ear, nose, throat, neck
• Thorax, lungs, heart
• Abdomen, genitals, anus
• Trunk, spine, extremities, reflexes Hydration, skin turgor, colour, photometry MATERNAL EXAMINATION
History-specific examination (breasts, fundus, perineum, vital signs)
FOLLOW-UP EXAMINATION As indicated
• Laboratory tests (bilirubin, electrolytes, complete blood count)
• Consultation with obstetrician, pediatrician
• Local community service centres (community nurse, social worker)
Confirmed appointment with primary care doctor Copy of assessment records to family
prevention guidance, requests for laboratory test- ing, and re-admission criteria. Nurses would focus on infant care, development, and safety and secu- rity; parental support systems and concerns; and nutritional issues, including evaluation of breast- feeding techniques through direct observation.
Physician assessment would include taking perina- tal histories, reviewing hospital charts available at postpartum visits, newborn physical examinations, bilirubin photometry, and enquiry about or physi- cal examination to uncover maternal breast and perineal problems.
• The health form would be duplicate and bilingual (English and French). One copy would be retained for the hospital chart. The other would promote continuity of care by having parents pass it on to their community primary care doctors. If no such physician was identified, parents would be provided with information on medical and social services in their area and be offered the oppor- tunity to formally register to receive care in the Family Medicine Centre.
• Family medicine residents at the Family Medicine Centre would participate in the follow-up program a minimum of 1 half-day weekly during their horizon- tal learning experiences. They would receive struc- tured readings on newborn history and examination skills, neonatal problems, breastfeeding issues and solutions, and maternal postpartum concerns.
Residents would initially see, in conjunction with a staff physician, three newborns, their mothers, and any other accompanying family members. They would also periodically observe assessments per- formed by nurses. Residents would then be per- mitted to see patients on their own, based on past training, newly acquired experience, and general comfort level. Case review with the staff would be required before families were sent home. Issues pertaining to urgent or ongoing home assessment would be discussed and initiated with local commu- nity service centres (CLSCs). Actual resident learn- ing experiences in such home assessment would occur elsewhere in the resident curriculum.
Evaluation
Newborn and maternal care. During a 1-year period surveyed, our program supported just over 2300 newborn visits. Residents received a structured learning experience through 20 to 30 newborns and their families, the total depending on the number of births occurring during an individual resident’s rotation.
A convenience audit of a random month’s activity indicated that, of 331 hospital deliveries, 227 (68%) met the criteria for our follow-up program. Most (205, or 90.3% of the 227) patients booked actually attended.
Telephone follow up of the 22 non-attenders indicated that 11 were otherwise seen by their community doc- tors in the requisite time. The remaining 11 either forgot the appointment or did not want to come.
Seventeen mother tongues in addition to English and French were identified (Vietnamese, Romanian, Polish, Urdu, Greek, Arabic, Chinese, Spanish, Portuguese, Italian, Hungarian, Cantonese, Bengali, Tagalog, Kampuchean, Sinhalese, and Tamil).
Primiparas represented 37.1% of the 205 mothers seen, multiparas 62.9%. Almost all babies (95.6%) were born at 37 weeks’ gestation or more, and 98.5% had birth weights of 2500 g or more. Jaundice was appar- ent in 39 (19%) of the 205 infants; of these, high photometry bilirubin readings led to ordering serum bilirubin assessment in 21 cases. Nine newborns were identified as being at risk for poor intake, weight loss, or dehydration. A few other concerns were identi- fied by doctors or parents: skin rashes (three cases);
appearance of penis (two cases) or umbilicus (two cases); musculoskeletal disorders (two cases); and nonspecific signs of possible cardiac, gastrointestinal, ophthalmologic, respiratory, or inflammatory conse- quences (five cases). None of the neonates were re- admitted during the audit month.
Maternal problems or concerns were reported or found in just over 47% of mothers. Incidence of breast engorgement, nipple fissure, or breast pain was 17.6%;
of perineal problems (episiotomy pain, hemorrhoids, constipation) was 14.6%; and of a combination of wor- ries revolving around abdominal and back pain, fatigue, edema, and anxiety was 18%.
Observation of feeding technique was recorded for 64.7% of cases (although, because documentation of this activity was incomplete, actual incidence is believed to be higher). In 36.1% of cases patients were counseled on breastfeeding; in 20% on cord care; in 16.6% on skin care; in 4.4% on nonspecific nutritional issues; and in 4.5% on circumcision and newborn perineal care.
Resident teaching. Teaching staff have indicated that this program represents a substantial improve- ment over the previous “hit or miss” practice in more traditional hospital programs. Staff and residents have indicated that there is sufficient volume of patients and of neonatal and maternal problems on which to base ambulatory postpartum learning. Residents
comparing this program with other learning experi- ences give it some of their highest praise, from both practical and pedagogic perspectives.
Residents report that interactions with both family physicians and nurses allow them to acquire a broad knowledge base for their own future practices. They indicate that the duplicate record sheet reinforces for them the importance of continuity in transmitting patient data to other health care personnel. Further, because some newborns are accompanied to the visit not only by their mothers, but also by their fathers, siblings, and grandparents, some residents have spo- ken of the opportunity to observe the early restructur- ing of families, and of the behaviours of people from diverse ethnic backgrounds. Finally, recent gradu- ates who wish to work in this program sometimes have to join a waiting list, another indicator of the program’s success.
Discussion
Outcomes in maternal and newborn care. Early discharge research suggests approaches should be based on patient outcomes.10 Mathematical models for length of neonatal hospital stay,11 odds ratio analyses for factors responsible for re-admission,12 and cost analyses on how early discharge affects neonatal re- admissions13,14 have all been reported. Breastfeeding problems, malnutrition, dehydration, hypernatremia, jaundice, and sepsis are described as causes for hospital re-admission.1,15-18 By contrast, a Wisconsin case-control analysis19 and a Kaiser Permanente ran- domized control study20 found no links between rapid discharge and re-admission. Critical reviews, however, cite methodologic problems as the cause for such conflicting findings.21-23
The North American follow-up guidelines cited ear- lier4,5 might not be easy to apply in some settings. For example, a Michigan community hospital educated its pediatricians on the guidelines. A survey of their patterns of practice over an 18-month period indicated no significant differences during the first 7 months in office follow-up scheduling for newborns, whether dis- charged less than or more than 48 hours postpartum.
By the end of the review, just over a third of short-stay newborns were seen anytime between 4 and 14 days after discharge.24
Relevance of program. In view of such findings, new approaches to follow up of early discharged new- borns and mothers seems justified. We have described a program that operated in a teaching milieu and was partially motivated by teaching objectives. We believe,
however, that similar projects can be implemented in non-academic community settings of various sizes.
For physicians who cannot guarantee rapid postpar- tum follow up, a roster of colleagues similar to ours would ensure community coverage. Hospital or office resources and personnel might similarly be negotiated or shared, and a mutually approved comprehensive record form would promote continuity and standards of care. If optimal nursing resources are unavailable, other office staff might assist physicians, as likely already occurs in many practices caring for children.
Only nine of 205 neonates were found to have prob- lems with potentially immediate consequences. In the absence of a specific cost-benefit analysis, however, a Kaiser Permanente study indicating that a follow-up program for early discharged neonates can reduce urgent care services by almost 50% is reassuring.25
Another concern about our program is that it could be difficult for mothers and newborns to attend, espe- cially when travel distances can be 20 km or more in a large city. However, our high rate of attendance suggests the contrary. As well, family interactions we have observed suggest that this outing helps many to get themselves up and out and begin doing activities with newborns outside the home. Unsolicited feed- back from some parents indicates that they appreci- ate the unique combination of early interdisciplinary input, comprehensiveness, and sensitivity to multicul- tural needs.
Comparison to other follow-up programs. Various regional home visitation models have been described and evaluated for their potential and generalizability.
Making conclusions is difficult, however, because rigorous methods are limited, outcome measures are different, and policy makers sometimes play con- founding roles.26
Our program could, in fact, offer benefits over home visit assessments by nurses. Specifically, it can offer more efficient use of resources by reducing travel, thereby freeing up nurses’ time for more direct contact with patients and more interaction with physi- cians. A nurse visiting every newborn at home can see an estimated three or four babies in a half-day, limited in part by community size, driving conditions, parking regulations, and travel costs. In our program, interdisciplinary evaluation is likely more extensive, and yet can be done for as many as 12 newborns and mothers in a half-day. Further, very early direct obser- vation in the home might not be necessary for all fami- lies. We identify infants or families at risk, and local community service centre teams can then intervene
rapidly from that point. An American 20-year random- ized trial of prenatal and postnatal home visits by nurses concluded that the neediest families benefit, but the broader population benefits little.27
Additional advantages over nurses’ home visits are postulated. In our model, most mothers obtain help from the father or another family member to come in, so we have opportunities to obtain their input.
Presence of people other than mothers might be less common in traditional home visits. As well, since the average family spends about 1.5 hours at the Centre, they have opportunities in the waiting area assigned to the program to talk and share experiences with
other parents at exactly the same postpartum stage.
Finally, rapid access to laboratory services or to hospi- tal re-admission appear to be particular advantages both in initiating further care and in decreasing paren- tal anxiety.
Conclusion
Our model of practising and teaching ambulatory new- born and maternal postpartum care seems to reduce poor outcomes of rapid hospital discharge. The model is relevant to other milieux, although variations in struc- ture or function might be needed to meet individual community requirements. Advantages and apparent positive outcomes that have been described need to be further explored through more quantitative analysis.
A tool is currently being developed to compare res- idents’ prerotation and postrotation knowledge, atti- tudes, and skills in newborn and maternal postpartum assessment. More specific definition of family satisfac- tion with the services provided is also necessary, as is a survey of community primary care doctors to ascertain whether they perceive we are truly facilitating early care of neonates in their practices. Finally, analysis of the effects of our early assessment and anticipatory guidance appears to be worthwhile.
Competing interests None declared
Correspondence to: Dr Mark J. Yaffe, Family Medicine Centre, St Mary’s Hospital Centre, 3830 Lacombe Ave, Montreal, QC H3T 1M5; telephone (514) 734-2676; fax (514) 734-2602; e-mail myaffe@po-box.mcgill.ca
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Editor’s key points
• This article describes a new model of postpartum maternal and infant follow up within 2 days for newborns discharged before 48 hours.
• All women and newborn infants are invited to attend a postpartum assessment clinic staffed by nurses, family physicians, and their residents, with specialist backup.
• This model offers a good opportunity to identify feeding problems, jaundice, maternal breast and perineal discomfort, and early parental adjust- ment concerns and to promote breastfeeding.
• Residents benefit from concentrated exposure in an ambulatory setting to early postpartum care, an experience not readily available in usual training programs.
Points de repère du rédacteur
• Cet article décrit un nouveau modèle de suivi de la mère et de l’enfant après l’accouchement dans les deux jours suivant un congé de l’hôpital qui s’est produit dans un délai de 48 heures ou moins après l’accouchement.
• Toutes les femmes et leur nouveau-né sont invités à se présenter à une clinique d’évaluation péri- natale où les soins sont dispensés par des infir- mières, des médecins de famille et leurs résidents, avec l’assistance d’un spécialiste.
• Ce modèle offre de bonnes possibilités d’iden- tifier les problèmes d’alimentation, la jaunisse, l’inconfort des seins et du périnée chez la mère, ainsi que les préoccupations entourant le début de l’adaptation au parentage. Il permet aussi de promouvoir l’allaitement maternel.
• Les résidents bénéficient d’une expérience ciblée en milieu ambulatoire dans le domaine des soins périnatals initiaux, ce qui n’est par facilement accessible dans les programmes de formation habituels.
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