The OB/NEWBORN scope of service includes routine vaginal births, external cephalic version, ante-partum testing, elective and emergency primary and repeat cesarean sections, pre-induction cervical ripening, labor induction/augmentation, low-risk VBAC (vaginal birth after C-section), stabilization of a sick neonate for transport and stabilization of the preterm or term patient for transport.
Family medicine hospitalists do all deliveries and take care of all mother baby pairs unless HROB (high risk OB) consultant assumes care of the mother (especially post-op) or pediatrics assumes care of an ill newborn. The average healthy mom/baby pair stays for 48 hours. This is because most of the patents will be returning to a remote village where access to care and travel back to Bethel may be difficult. Some exceptions are be made for Bethel patients who may leave as early as 36 hours. For billing purposes if a mother or baby is staying longer than 48 hours (or 2 hospital days) a justification for the increased length of stay must be given. If a patient delivers later in the evening, yet before midnight, consider discharging the mom and baby to pre-maternal home in the evening for travel home the next day.
There is a pediatrician available for newborn consultations. Pediatricians attend all C-Sections and any deliveries of infants who are less than 36 weeks gestation or as requested. Pediatricians also attend any deliveries where there is evidence of fetal distress. Pediatricians will come to any delivery that a FM physician has concerns about the fetal/newborn status. We do not intubate for meconium, so if there are no other concerns the pediatrician does not need to be called. We try to transfer higher risk moms to Anchorage before they deliver. If mom is less than 36 weeks gestation, it is best to get mother to Anchorage for delivery because the babies generally need a NICU or special care nursery. Some babies that are delivered between 36 and 37 weeks do fine, but some will have problems with feeding and maintaining temps. These babies will be need to be transferred to Anchorage if they are or are requiring more than routine care for any length of time. Moms may travel with babies that are being transferred if it has been more than eight hours after delivery and they are stable post partum.
All sick newborns should be seen by the pediatrician to arrange or assist in arranging a transport via LifeMED with or without a NICU NP.
Because there is no nursery and limited nursing staff, all babies that need more than mother’s care must be transferred to Anchorage. Each delivery room is set up for initial resuscitation. If a baby requires ongoing resuscitation or intubation, they are moved into the nursery procedure room that has two resuscitation beds. There are two neonatal crash carts, one in the procedure room and one on the unit across from the nurse’s station. The carts have all the needed resuscitation supplies and medications needed for resuscitation. On top of each cart are neonatal resuscitation worksheets with equipment sizes, medication doses, and fluids based on weight or estimated gestation age to guide resuscitation.
The goal of OB nursing and provider staff at YKHC is to ensure the safest delivery and the best care possible for our newborns as well as promoting good maternal-newborn bonding and avoiding separating moms and babies whenever possible.
Occasionally infants will be delivered that will need further evaluation, observation, interventions and/or transport to a higher level of care. Because we do not have a nursery or the staffing level to care for sick infants we need to decide which baby’s will need to be transported out. We can do some limited observation and supportive care, but for all sick infants that require a higher level of care, providers will stabilize and transport the patient as quickly as possible.
If a newborn has a possibly transient condition (examples: TTN, low glucose, minor depression from precipitous delivery etc.) a baby may be evaluated and watched in the nursery for a limited length of time. If the newborn is not showing signs of improvement and it does not appear that they can be cared for, as a rooming in patient, by mom by 4-8 hours of life (depending on staffing and nursing comfort level), arrangements will be made to medevac the infant.
If a newborn is stable and shows no signs of illness or instability (i.e. can room in with mom), but needs labs and observation for 48 hours (ex: GBS exposure without appropriate maternal prophylax¬is or jaundice and phototherapy) the baby may stay with mom in OB with or without a heplock in place. Heplocks will be monitored per hospital policy.
At this time, if a newborn is well, but has borderline or questionable screening labs that require 48 hours of antibiotics and observation, the infant will need to be transferred to NW or to ANMC.
Per new Joint Commission rules (and good practice), we have to do debriefings on significant event that occur on the OB unit. These include, but are not limited to: postpartum hemorrhage, severe hypertension, transfusion of more than 4 units of blood and emergency cesarean sections. We have a form to help with this. They don’t have to be long drawn out events. It can be as short as 5 minutes. Please document that a debriefing occurred in a separate note so we can track them and show JC that we are doing them.