EBB 269 – Mini Q&A on Early Newborn Discharge from the Hospital, Vacuum Delivery, and More!

Rebecca Decker:

Hi everyone. On today’s podcast, I’m going to do a mini Q&A about four different subjects.

Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker and I’m a nurse with my PhD and the founder of Evidence Based® Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi everyone, and welcome to today’s episode of the Evidence Based Birth Podcast®. I’m going to be your teacher for today’s episode and I am so excited to answer some of your questions that have been submitted to us. But before I get started, I do have an important announcement for you. We are opening applications for the Evidence Based Birth® instructor program next week. The EBB Instructor Program is designed for experienced birth workers and experienced healthcare workers who want to teach the official Evidence Based Birth® curriculum to both parents and/or professionals in their community. So EBB instructors can choose to teach EBB continuing education workshops, or they can teach the full EBB childbirth class to parents, or they can do both. So applications for the EBB instructor program open on Tuesday, June 6th. They will be open for three weeks and close on Monday, July 3rd. And those who are admitted to the instructor program will be able to begin their studies in August of 2023.

So if you want to learn more about becoming an instructor, just go to ebbirth.com/instructor and sign up for one of our free Q&A webinars to learn more about becoming an instructor and I will answer all of your questions. If you’re thinking about applying, we strongly recommend that you attend this webinar or that you at least watch the replay. So applications for this program open only once each year. So if you want to train this fall to become an EBB instructor and start teaching our classes or workshops, head to ebbirth.com/instructor right now to get an invitation to the Q&A webinar and find out more about how to apply.

And now I’m excited to share a mini Q&A with you. We made the decision earlier this year that whenever there are five weeks in one month, we will take that fifth week to do a mini question and answer session where I will select a few questions that have been submitted to us and answer them on the air. So our first question is, “How long does baby need to stay at a hospital after birth? Birth centers do early releases and let you go home before 24 hours. And I know some hospitals will release you and your baby after 24 hours stay, but my hospital does not. They say that the 48-hours stay for the newborn is mandatory.”

So here’s my answer. This is a topic that comes up a lot on birth plans. A lot of our EBB childbirth class students end up talking with their instructors about self-advocacy and how to navigate the situation. Some parents wish they could stay longer in the hospital and they want to make sure they have at least that full two days and nights, especially if it’s their first baby. Now, it used to be that there was a problem with hospitals kicking people out of the hospital early after they had a baby. In the United States, they actually had to pass a federal law in 1996 called the Newborn and Mother’s Health Protection Act, which basically says that with health plans, they have to cover at least the first 48 hours of a stay after a vaginal birth and the first 96 hours after a cesarean.

If you go to the US Department of Labor’s website, they state, “The Newborn and Mother’s Health Protection Act, also sometimes called the Newborn Act, includes important protections for mothers and their newborn children with regard to the length of hospital stay following childbirth. The Newborns Act requires that group health plans that offer maternity coverage pay for at least a 48-hour hospital stay following childbirth or a 96-hour stay in the case of cesarean section.” And those clocks start at the moment of delivery. There’s also a frequently asked questions about this act on the Department of Labor’s website and they say, “However, the attending provider may decide after consulting with you to discharge you or your newborn child earlier.”

And so that’s what this parent is asking for. They’d like to go home earlier if possible. So you see, we used to have the opposite problem. They were discharging people to make room to open up beds and people were being discharged too early against their will. So the law was changed to require that you received care for at least 48 hours with a vaginal birth in 96 hours with the cesarean, which makes some intuitive sense because when your milk is coming in at 48 to 72 hours, that’s a great time to have extra lactation support easily available. But now we have some people who have the opposite problem. They would prefer to go home early and to do their recovery at home with their baby earlier than 48 hours, but the pediatric department in many hospitals won’t let them.

So I checked the American Academy of Pediatrics to see if they had any guidelines on this, and they do. They had some guidelines that were re-released in 2015. I’m going to read you a quote from their 2015 statement. The name of their statement is called Hospital Stay for Healthy Term Newborn Infants. And they state, “The length of state of a healthy term newborn should be based on the unique characteristics of each mother-infant dyad, including the help of the mother, the health and stability of the infant, the ability and confidence of the mother to care for her infant, the adequacy of support systems at home, and access to appropriate follow-up care. Input from the mother and her obstetrical care provider and nursing staff should be considered before a decision to discharge a newborn is made. And all efforts should be made to keep a mother and newborn together to encourage on-demand breastfeeding and to ensure simultaneous discharge.”

They also go on to give a list of criteria that they recommend be met before hospital discharge, especially for those who are healthy term newborns and the parents would like to take their baby home earlier than 48 hours. The list of criteria is pretty long, but most of it makes common sense, such as like the newborn has normal vital signs and there don’t seem to be any complications or abnormalities, that the baby has been urinating regularly and has passed at least one stool and had at least two successful feedings, and there’s no bleeding if they’ve been circumcised, that sort of thing. So the list kind of goes on for a while, but they’re all, for the most part, basic common sense reasons of things you’d want to look at before a baby goes home.

So if you find yourself in a scenario where you have a healthy newborn act term and you want to go home before 48 hours from your hospital but the pediatric department won’t let you, this is a scenario where it can be really helpful to know are there any medical reasons for you and your baby to stay the full 48 hours or maybe are there social reasons you might want to stay for the full 48 hours. For example, does your baby have concerning signs and symptoms that require closer monitoring? Or do you need more support and assistance with breastfeeding or body feeding because maybe your baby isn’t latching that well yet? Or maybe you as the parent need more support in monitoring because maybe you had a postpartum hemorrhage or some other kind of complication.

On the other hand, what are the reasons for going home early? Do you feel like you’ll recover more easily at home? And do you have support lined up? Do you have other children that you want to get back home to? It can be helpful in these situations to think about the three-legged stool of evidence-based care. What does the evidence say about your situation? Or does it have nothing to say at all? Do you have a care provider who stays up to date on the latest evidence and is even aware of the guidelines? And what are your values, goals, and preferences as the parent?

If you decide you want to go home early with your baby but your hospital has a generic policy that you “cannot,” this is where you need to practice using your voice and your self-advocacy skills. There is a way that you can speak up for yourself and your baby in a manner that does not alienate healthcare workers. We talk more about advocating for yourself and the different methods you can use in the EBB childbirth class. But if this is something you know you want, that if you and your baby are healthy, you want to go home from the hospital early, then you might need to start your self-advocacy early long before you go into labor. You also might want to seriously consider switching hospitals if that’s an option for you.

Another tip that most people don’t know is that you do not have to use a pediatrician to care for your baby in the hospital. Many hospitals also have family medicine physicians, also commonly known as family doctors or family practitioners. You can request or find a family doctor or family practitioner to be your baby’s provider. Unfortunately in many hospitals, the nurses almost always default to “admitting” the baby to pediatrics. But some family doctors and family practitioners may practice more holistically and maybe more likely to individualize your care. And then again, different pediatricians have different practice patterns. And you have the power to interview your pediatrician long before you give birth. So you can choose who is going to be caring for your baby with you and find someone who is aligned with your preferences.

All right, next question. So an influencer recently tagged us on Instagram on a story about the evidence on big babies, which was interesting because then we started getting messages from a lot of different people. Some of them said things like, “My baby was measuring the 99th percentile the whole second half of my pregnancy. At 37 weeks, a growth scan show they were eight pounds already so I agreed to an induction at 39 weeks. And wow, it’s a good thing I did because the baby was 9 lbs. 9 oz and we had a shoulder dystocia.” And then other people would message us saying the opposite. Someone said, “I had two ultrasounds telling my baby was big at 22 weeks and 32 weeks. Then at 40 weeks an ultrasound showed he was right on track. So I listened to my gut and refused the induction, and I’m so glad that I did.”

So here’s my response to everybody who was writing into us, to remember that stories are helpful and everyone’s experience is valid. Also, I know that we often learn best through listening to stories, but individual stories can also be taken into context. Just because something happens to one person does not mean that it will always happen to everyone. Fortunately at EBB, we do have a lot of research that can help you understand the concept of big babies. So Big Babies was one of the first EBB signature articles we ever published, and it was recently updated at ebbirth.com/bigbaby.

One of the common questions we’ll get about measuring the baby’s size is, “Well, that data is old back then the ultrasounds were inaccurate, but modern ultrasounds are much more accurate today.” And that’s not the case. Ultrasounds today, even the 4D ones, still have trouble accurately predicting the weight of the baby. Sometimes they will be right and sometimes they’ll be wrong. And actually the research statistics show that about half the time if it predicts that your baby will be large, the ultrasound will be right, and about half the time the ultrasound will be wrong and you won’t have a big baby. So because of that, we get stories on both sides.

But if you really want to know the evidence on big babies, I encourage you to check out the article at ebbirth.com/bigbaby, that’s all one word, bigbaby. There’s also a podcast which is episode 190 of the Evidence Based Birth® Podcast, and we have a one-page handout you can share with your provider to start discussion if you’re pregnant or you can give out to clients if you’re a nurse or midwife or doula.

The next question I want to share with you is, “What is the maximum amount of time that doctors can use a vacuum device to help get the baby out?” And here’s my response. So there are a lot of misconceptions about vacuum assisted deliveries. I had a student in a childbirth education class who recently told me that they were terrified of having a vacuum assisted delivery, which I found interesting because I personally experienced a vacuum delivery myself. And although this procedure does have both benefits and risks, in my case, the vacuum helped me avoid a cesarean surgery due to fatigue from pushing for a very long time. And then that ended up making an impact on my future health because I was able to go on and have several vaginal births after with subsequent pregnancies. And I did not have a history of prior cesarean on my record so it made my future births go more smoothly because I had a vacuum assisted delivery instead of a cesarean.

However, we do know that there are risks and disadvantages to using a vacuum assisted delivery. But it can also be helpful in an emergency where a baby needs to be born quickly and the vacuum assisted delivery would be faster than a cesarean surgery. So I know there’s a wide range of experiences and fears and anxieties related to vacuum assisted deliveries, and I get that. Whenever you come across something that feels frightening, it can actually be really helpful to understand the evidence and to get empowered with information. So we cover the evidence on vacuum delivery and forceps delivery, which are sometimes referred to as instrumental deliveries or assisted vaginal deliveries. We cover these in the Evidence Based Birth® Pocket Guide Interventions, and we cover them in EBB Podcast episode 244, which is the evidence on the artificial rupture membranes, assisted vaginal delivery, and internal monitoring.

So there are many different safety criteria that need to be considered if you are thinking about having a vacuum assisted delivery. And there are also safety practices that they should be using if you do have a vacuum assisted delivery. So we cover some of those in that podcast episode, and I really encourage you to check it out. But to answer your specific question about how long they can apply the vacuum or suction device to your baby’s head, I checked UpToDate, which is a subscription only website where they write literature reviews for doctors. So it’s primarily used by clinicians and not really available to the public unless you pay for a subscription. In their article on assisted vaginal delivery, they write, “The maximum time to safely complete a vacuum assisted delivery and the number of acceptable pop-offs are unknown.” I’m going to stop, pause the quote there and just let you know a pop-off is when the vacuum kind of pops off the baby’s head.

All right, we’ll go back to the quote now. “A maximum of two to three cup detachments, three sets of poles for the dissent phase, three sets of poles for the outlet extraction phase, and/or a maximum total vacuum application time of 15 to 30 minutes are often recommended. Although most authors advise lower application time limits. These recommendations are mostly based upon common sense and experience, but are supported by two studies assessing the risks associated with cup detachments and duration of the procedure.”

So although this is something you might not really be thinking about if it comes to needing a vacuum assisted delivery, it’s helpful to know that 15 to 30 minutes is really the max safe time that the vacuum can be applied, that that suction can be applied to the baby’s head to assist with the birth. And it might be helpful for a family member advocate to keep an eye on the time to make sure that they are not overusing this intervention. And again, I love how we were able to cover it in the pocket guide and kind of talk all about the research on assisted vaginal delivery and the research on the benefits and risks. So go to episode 244 of our podcast if you want to learn more.

The final question that I wanted to address is, “Has EBB come out with any new resources lately that I should know about?” Well, as a matter of fact, we do have brand new handouts that I want to share with all of you. So you may or may not have heard that we had a new article about the evidence on anti-racism and healthcare and birth work. This latest signature article is the result of a year and a half of hard work from Ihotu Ali, MPH, a research editor here at Evidence Based Birth®. Ihotu and I work together to create these four handouts that we hope that you all can put to use.

First of all, we have a handout all about the research on pelvic shapes and how trying to determine someone’s shape of their pelvis is an outdated practice that’s based in scientific racism. So that’s an important handout to have on hand if anybody is telling you that your pelvis is incorrectly shaped to give birth to a baby. The next handout we have is it’s a getting started on anti-racism handout. This handout covers all of the different resources that we like to point people to when they’re getting started in the area anti-racism journey, including our top recommended books, education, and online courses, many of them free, Black-led community birth and doula trainings that we urge you to support if you’re thinking about taking a doula training, anti-racism practice groups for white allies, podcasts, films, and more. So that one is a two-page handout where you can kind of go through it like an optional checklist to decide which resources you want to access.

The next resource is a handout on examples of how we can take action to support the Black Birthing Bill of Rights. The Black Birthing Bill of Rights was created by the National Association to Advance Black Birth. You can follow them at the NAABB on Instagram. This bill of rights is a set of illustrated patient rights and affirmations. You can read the entire Black Birthing Bill of Rights at thenaabb.org and download PDFs there to learn more about this powerful visual.

And with permission from the NAABB, we selected six principles from the full Black Birthing Bill of Rights to adapt into a table and put that table in handout. We made this handout freely available and we hope that it will inspire people to take several action steps to integrate into their advocacy. So there’s one column that talks about our future, and that lists the principle from the Black Birthing Bill of Rights. And then the middle column says Our reality, and it has research statistics on what is actually happening in the healthcare system right now. And then the column on the right has advocacy and action items that we can help turn our future into our reality. I think this hand out would be especially good for people who are taking doula trainings or who are in nursing or midwifery schools. It would also be helpful for medical students and residents.

Another free handout is a really simple quiz that you can print off and share with others, a quiz on anti-racism. This was developed with medical students, residents, and attending physicians in mind. So again, something you can print off and share with doctors and students. It lists a variety of terms and then asks you to circle the rating that best describes your familiarity with the different terms. And then it has a little scoring guide with suggestions for how you can educate yourself if you don’t know about these subjects. I took that handout to a presentation that Ihotu Ali and I did when we were working on this article, and we gave it out to medical residents. It was really interesting to see their reactions to looking at this list of items and figuring out what they knew and didn’t know about the history of racism and anti-racism in their own field.

And then finally, we have a handout all about anti-Black implicit bias and how this actually plays out in the medical field and in birth labor and delivery care in particular. This was a handout we put together to hopefully open the eyes of white healthcare workers and white birth workers as to the ways different racial biases turn into actions in the labor and delivery room, what effect they can have and what are some antidotes. We have scripts for how you can speak up if you see these different actions occurring. If you see biases in action, what can you say? What can you do to interrupt that racialized harm? This is a little bit longer of a handout. It’s nine pages long. But again, I really hope that this is something that especially students can use in their training.

And I also encourage you to get a copy of this, maybe leave it at the nurse’s station or at a residence break room so that other people can read through and learn about the biases and open their eyes to actions that they or others might be taking that are actively causing harm in their unit. We also give suggestions at the end for how you can deal with your emotions as you are learning about these subjects. And we recommend the book My Grandmother’s Hands by Resmaa Menakem. It’s a book intended to help us begin healing from intergenerational trauma caused by racism. So all of these free handouts can be accessed at ebbirth.com/antiracism. I encourage you to visit our newest signature article. You can listen to the podcast that goes along with it and download these handouts and add them to your toolkit to use to educate others so that we can hopefully use this information to make a difference in our local hospitals.

So thanks so much for joining me today for this mini Q&A. We’ll put the links to all these resources in the show notes. We have a really exciting lineup for the next month of guests and topics. So I can’t wait to get started on the next month with you all. Thanks again for listening and I’ll see you next week.

Today’s podcast was brought to you by the signature articles at Evidence Based Birth®. Did you know that we have more than 20 peer reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com? It takes six to nine months on average for our research team to write an article from start to finish, and we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebased birth.com, click on blog, and click on the filter to look at just the EBB signature articles.