Friday, May 11, 2007

No Prenatal Care

I tell you, it's enough to strike terror into the heart of a NICU nurse when those words appear on the monitor screen that connects us to the birthing center.

No Prenatal Care.

That means no labs, unless mom's labor lasts long enough for us to get them, but that's not nearly common enough.

We don't know if the baby needs to be treated to prevent HIV - and won't for at least 24 hours. The medications aren't risk-free, so we can't just give them to everyone. They're most effective if mom was treated antenatally and the treatment continued for weeks after birth. Delay in treatment can increase the risks. When an HIV positive mom is treated during the pregnancy, and when she has good prenatal care and the pregnancy can be carried to term -- and when the baby receives the full course of prophylactic treatment, the transmission rate is about 1%.

For preemies of untreated moms, it's considerably higher -- even with medication after delivery.

We don't know if the baby needs to be treated to prevent Hepatitis B.
On weekdays, we can generally get the labs back in time to prevent unnecessary treatment, but on weekends our only option is to give Hepatitis B Immunoglobulin in addition to the Hepatitis B vaccine. This is an avoidable injection -- and an avoidable expense. If only the mom had prenatal care. At least we can usually keep the baby from getting Hepatitis B - which is critical, because infants who contract Hepatitis B have a greatly increased risk of becoming carriers. That puts them at higher risk for cirrhosis and primary liver cancers.

We don't know if the mom is colonized with Group B Strep.
This can lead to otherwise unnecessary admissions to the Neonatal ICU. You can pretty much pay for the whole nine months of prenatal care - for at least one woman - by eliminating just ONE otherwise unnecessary NICU admission. When we don't know the mom's GBS status, we are much more likely to admit the baby to the NICU to start 3 days (minimum) of antibiotic treatment for symptoms we might observe in the well-baby nursery and follow with serial CBC's. Sick babies get admitted regardless, but certain variations from normal are much more likely to end up in the NICU if mom is GBS positive -- or if we just don't know.

The baby is at greatly increased risk of being small for dates.
Babies who are significantly smaller than expected for their gestational age are guaranteed a NICU stay and an expensive workup. We've had an epidemic lately of 1400 gram FULL TERM babies. That's just a hair over 3 pounds. None of the moms had prenatal care.

Those babies are at increased risk of developing necrotizing enterocolitis - a serious condition which can be life-threatening, can require surgery - and at the very least, requires weeks of IV feedings and antibiotics. None of our recent little ones has had NEC, but they all get really hungry before we feed them. Depending on the birth weight and the mom's choice of breast or bottle, that can be as much as 5 days after birth presuming there are no symptoms of NEC. They need IV feedings which are phenomenally expensive. 5 days of TPN c0uld cover 9 months of prenatal care AND food supplements for several women.

The babies are at increased risk of a variety of developmental delays and congenital anomalies.
This is because of undiagnosed maternal factors (diabetes, poor nutrition, substance abuse, hypertension, viral illnesses, etc). Many of these, if managed prior to and during pregnancy do not need to lead to negative outcomes.

You have no idea of the gestational age.
With ultrasound imaging - possible if mom does not present fully dilated - you at least have an idea of the size of the baby and can be prepared for that. Size alone does not help much in determining gestational age. Small for dates infants are more mature than you would guess from size alone and infants of diabetics may be large, but premature.

Undiagnosed multiples.
Yes, we're prepared for all possible outcomes, but the very last thing you want to hear in the delivery room is, "I think there's another one in here," when you had no reason to expect twins. It's not pretty - and ultrasound imaging has virtually eliminated that scenario, but if a mom comes in fully dilated and crowning, there just isn't time.

Prenatal care is available for FREE in many areas and at greatly reduced cost in others. It's a worthwhile investment. Not only does it reduce costs to the point that it pays for itself - just in reduced NICU admissions and maternal morbidity, but it pays for itself in reduced long-term problems for the babies. It's not just about the money, of course. Improved outcomes for the babies is the most important thing, but the money isn't unimportant. We have a finite number of health care dollars and saving dollars while saving babies just makes sense.


Clark Bartram said...

"When we don't know the mom's GBS status, we are much more likely to admit the baby to the NICU to start 3 days (minimum) of antibiotic treatment for symptoms we might observe in the well-baby nursery and follow with serial CBC's."

What NICU do you work at? Stop, don't answer that. I'm just saying that if the Red Book algorhythm is followed then that situation shouldn't happen very often. If a child is over 37 weeks(on exam if you don't trust the dates), there is no maternal fever and no prolonged rupture(>18 hours), then no IAP is needed and no increased itchiness of the trigger finger is required. If the OB was really worried they could give a dose of PCN >4 hours before delivery. And for C/S without labor or rupture there is no need for increased concern either. We do a 48 hour rule-out. I've never heard of a 72 hours stay on abx.

Judy said...

72 hours has always been our routine, although lately I've noticed it being shortened to 48 in term kids.

If GBS is unknown, mom will generally get antibiotics while in labor -- providing there is enough time. Typically the potentially avoidable rule-out admits occur when prenatal care is spotty or non-existent, GBS is unknown, labor is too short for antibiotics, and mom doesn't provide a stellar history in regard to length of ROM. Also, the baby generally presents with what, in retrospect, appears to be transient tachypnea. Decidedly not a big part of our patient population.