PC2152: Reducing Risk of Morbidity in Term Infants After Out-of-hospital Birth

Introduction: While planned home births constitute a small percentage of all deliveries in the U.S, numbers have increased since 2004, peaking during the COVID-19 pandemic. An increase across all racial and ethnic groups has been described. Many factors influenced this trend, including the COVID-19 pandemic, cultural beliefs, mistrust of the medical system, and financial burden. State legislatures have recently enacted regulation of midwifery practice and financial coverage of home births, to ensure safety and coordinated follow-up care of the newborn. We present two cases of term neonates with encephalopathy following planned at-home births, highlighting disparity in postnatal care between home and hospital delivery.

Case Description: Infants A and B were each born after uneventful pregnancy and uncomplicated delivery by a midwife. Neither infant was evaluated by a pediatrician. Infant A, a non-Hispanic Black male, presented at 3 days of age, with severe jaundice, decreased activity, and poor feeding. On admission, total bilirubin was 35.6, direct fraction 3.2, negative Coombs and elevated reticulocyte count. Examination was remarkable for severe jaundice, retrocollis, opisthotonia, and hypertonia. Infant B, a non-Hispanic White male, presented at 5 days of age with jaundice, poor feeding, and irritability. Examination was significant for irritability, posturing, back-arching, full anterior fontanel, and severe jaundice. Total bilirubin on admission was 24, negative Coombs and normal reticulocyte count. Each infant received intensive phototherapy and double-volume exchange transfusion. Video EEG showed electrographic seizures requiring phenobarbital and levetiracetam for both infants. Neuroimaging showed signal changes in the globi pallidi and subthalamic nuclei consistent with kernicterus for Infant A, and restricted diffusion of bilateral hippocampi for Infant B.

Discussion: These cases highlight the importance of adherence to American College of Obstetricians and American Academy of Pediatrics (AAP) guidelines regarding follow-up for neonates following out-of-hospital birth, to avoid missed diagnoses of preventable conditions. There are several key factors to ensuring a safe home birth, including appropriate personnel and equipment, access to consultation and timely transport to a nearby hospital. There should be no disparity in newborn care for home versus hospital delivery. While hospitals are regarded as safest for delivery, studies have shown that women with low-risk pregnancies can safely deliver at home with availability of appropriate resources. It is important to appreciate that unexpected complications may still arise, despite low-risk candidacy. This affirms the need for attendance of two competent health providers (including one NRP-trained provider assigned to care for the neonate), and timely infant follow-up after home deliveries

Conclusion: Out-of-hospital births can be a safe process when guidelines for maternal and newborn care are followed. We presented two cases of infants born at home who did not receive AAP-recommended newborn evaluation. Timely medical follow-up of infants born at home mitigates preventable neonatal complications that may ultimately impact long-term outcome.