Isaac Shrier Goldman, five days old and just over eight pounds, is getting the once-over from Sinai Hospital nurse Betsy Tritt. His crying suggests he doesn't exactly enjoy having his umbilical cord checked, but at least it's on his mother's lap at home in Mount Washington with the soothing tune from a music box and the animated chirps of two older sisters.
Meanwhile, his mom, 34-year-old Michele Goldman, takes the opportunity to discuss how things are going with Mrs. Tritt. Breastfeeding is working well, she says; Isaac has gone through an impressive number of diapers. Her biggest problem so far has been an ugly -- but normal -- skin rash that he developed. Mrs. Tritt, who specializes in maternal-child care, reviews the best ways of treating it.
With post-partum hospital stays growing shorter and shorter, home care nurses like Mrs. Tritt are becoming crucial monitors of the health of newborns and their mothers. They help teach anxious, exhausted new mothers -- who often spend only one night in the hospital after giving birth -- how to breastfeed, burp and bathe their babies. They also check the newborns for breathing problems, jaundice, dehydration or other physical ailments that often crop up in the first few days of life.
And business is booming.
This week, roughly 700 nurses, midwives, administrators, educators and home health workers from as far away as Alaska are attending the nation's first conference on perinatal (occurring around birth) home care at the Baltimore Marriott Inner Harbor Hotel. The size of the four-day meeting, which ends tomorrow, reflects the rapid growth of home care nursing -- a result of dramatic changes in the treatment of high-risk pregnancies and post-partum patients.
Fewer and fewer insurance companies will pay for new mothers to stay more than one night at the hospital. In states like California, hospital stays for uncomplicated deliveries are being limited to six to 12 hours -- a trend that is likely to spread across the country.
Many insurance companies, particularly large HMOs, compensate for the quick discharge by paying for follow-up home visits.
Blue Cross and Blue Shield of Maryland, the state's largest insurer, plans to begin covering home visits for women discharged within 24 hours in March. But some insurance companies don't cover home visits, no matter how quickly women leave the hospital.
The continuing trend toward shorter and shorter hospital stays means that obstetrical nurses must shift their patient education to home.
Mrs. Tritt, who has been making maternal-child home visits regularly for the past several years for Sinai's home care program, says home visits allow her to instruct new mothers more effectively because "everything is so rushed in the hospital now."
While Mrs. Goldman seems serene, well-informed and surprisingly well-rested, not all of Mrs. Tritt's home care patients are this relaxed.
Many are anxious first-time mothers filled with questions and fears about taking care of their babies. For these women, visits from home-care nurses can be a badly needed lifeline for safe passage through the first transitions of parenthood.
"The two to three days we used to have to help the new mother learn is now less than 24 hours," Mrs. Tritt says. "Many of the new mothers are stressed out, and it's hard for us to help them learn what to do in the midst of all the telephone calls and visitors they get.
"First-time parents know better what they need to ask when they are at home. . . . They're very receptive and often have lists of questions for you to go over."
Health of newborns
No one is sure whether the practice of shortening hospital stays has affected the health of newborns, according to neonatologist John Britton, professor at the University of Utah Medical Center and author of several papers on the subject. He says existing studies have too many variables to draw conclusions.
"It's an extremely confusing area. There is no convincing data to support any choice of discharge time. To do a study would require thousands of babies randomized at different discharge times on a multi-center basis."
He continues to rely upon discharge guidelines drawn up in 1980 by the American Academy of Pediatrics. The recommendations suggest that full-term healthy infants should stay in the hospital at least six hours or until the infant can establish feeding and be able to maintain a stable temperature. The academy also recommends a follow-up examination by a health-care worker within two to three days of birth.
Neonatal nurse practitioner Dianne Charsha from Presbyterian Hospital in Dallas says most babies are now discharged before they fully make the transition from fetal life to life outside the womb. They are often too sleepy to feed well before they leave the hospital. And because a new mother's breast milk doesn't come in fully for 24 hours post birth, breastfeeding is often not well established before mother and baby leave the hospital.
"Sometimes we have issues with hearts and lungs not being fully transitioned," says Ms. Charsha. "Some of the babies at home may show signs that they aren't doing well, but have the moms picked up those signs?
"New mothers used to be educated about their newborns in the OB unit. Now the teaching focus has shifted to the pregnancy side [the pre-birth baby care and infant safety classes]. But it's hard to talk about what will happen before the baby is born. Questions like, 'She just doesn't burp, what do I do?' are very basic questions but harder to figure out than you imagined."
Home care nurses are also discovering situations they never learned about in school.
"We've found mothers who put their babies in bureau drawers," says Karen Zilka, client care coordinator for Johns Hopkins' Pediatrics At Home program. "Some mothers are heating their apartments with the gas stove in the kitchen. Or they are putting the formula out on the window sill in the back because it's cold outside -- but the sun is beating right down on the bottle."
The updated job description of maternal-child nursing also requires knowing danger signs for abuse.
"Imagine you've got a mother who is tox positive for having done drugs and is going home with this baby who has gone through some form of withdrawal," Ms. Zilka says. "With a mother doing drugs, a baby who is screaming and not doing well is at risk for abuse."
Asking about abuse
Some perinatal nurses at the conference attended a workshop on how to ask new mothers about spousal abuse or family violence.
Jacquelyn Campbell, full professor at the Johns Hopkins School of Nursing and chair of the American Academy of Nursing's expert panel on violence, says post-partum home visits provide excellent opportunities to recognize risk factors of abuse.
"I say, 'You've got to get it into your routine. Just like you check every baby's umbilical cord, you check every mom for abuse.' Nurses have to figure out a time to ask the male partner to leave the room during the examination and ask about abuse during that time."
Perinatal nurses must also be sensitive to physical and mental difficulties women may have with motherhood. The post-delivery period can lead some mothers into prolonged clinical depression. It may bring those with severe emotional problems -- especially women who have been abused -- to harm their children.
"Home nurses need to observe whether the mother seems to be bonding with the child, whether she understands that newborn crying is very normal and whether she is overwhelmed or depressed," says Dr. Campbell.
Despite the expanded duties that can accompany home visits, many in the field prefer this form of nursing.
"Home care takes nursing and medicine back to the home, where it originally started," Ms. Zilka says. "And there are great advantages to that. Because someone is going to be more natural with you, you will pick up on things you wouldn't in the hospital.
"The nurse can immediately assess a lot of things she's teaching about, like making sure the home is infant-safe and making sure the mother has the right supplies at home.
"Patients are generally more open to listening to things you have to tell them when you're on their territory and they truly control the situation. In the hospital, the new mother doesn't have control. At home, it's her turf."