Early discharge programme

Hospital stays for babies and mothers are aimed to ensure that families are recovered and prepared for bringing your child home. In this document we will try to prepare you for what to expect in the coming days and what to look out for. Remember that, at any point, you can call your Community Midwife for advice, or after hours you may present to Dubbo Emergency Department where nursing and medical staff can help you.

This document is not a NSW Health document, but it an attempt to provide general information for families with new born babies.

Early discharge from a labour ward can occur after 4 hours if your pregnancy was low risk and there are no after birth issues for you, the mother, or after delivery issues for your baby. On occasions medical problems may arise after the first 12 hours of life, and it is the job of the nursing and medical staff to help find them. In part this is related to the change from your baby being in the womb to needing to survive on its own. In particular heart disease may be hard to pick up within the first 24 hours of life. This information sheet aims to give families who wish to discharge early, some advice on what to look for and when to seek attention. Please note that this is only a guide, and if you have concerns please seek medical attention.

Feeding:

Feeding, particularly for first time families, it can be difficult to tell whether your child is latching well, sucking well or taking enough breast milk or formula. It is important before you discharge that you and the midwifery team are happy your child’s feeding, whether that is breast or bottle feeding.

Breast feeding

Breast feeding is the preferred feeding for babies and has many advantages over formula. However it may be hard to know if you making enough milk, so please ask your midwife to help support you in breast feeding, especially if it is your first time.

Signs of good breast feeding (and feeding in general) over the first 7 days of life:

Your baby is wide awake and looking at your face and/or the breast.

You are getting a good let down in milk with feeds.

Your baby attaches well to the nipple and sucks strongly for 20-40 minutes at a time.

Your baby passes urine a few times per day.

Your baby is going good numbers of poos.

Your baby only loses a small amount of weight after birth:  ideally less than 5% of birth weight, but certainly less than 10%

Signs that could mean your baby has less good feeding, possibly requiring support a medical review

Your baby is too sleepy, hard to wake up and wants to sleep for more than 6 hours on a recurring basis.

Your baby does not pass urine until after 24 hours of life. Your baby only passes urine once a day after the first 24 hours of life (your baby should do a “number 1 by the end of day 1”),

Your baby has orange-coloured urine: called “urate” crystals- this is a fairly clear sign your baby is dry

Your baby doesn’t pass a pooh until after 48 hours of life (your baby should “do a number 2 by the end of day 2”)

Your baby is floppy, doesn’t move much, and you are consistently worried it is “too quiet”

Your baby is starting to get more yellow in skin colour, from jaundice

If you have any concerns that your baby is not feeding well, you should consider staying in hospital longer until you are confident that your feeding plan is going well. Poor feeding can result in low blood sugars and excessive weight loss, which can have serious short and long term effects. As such, a baby with poor feeding cannot be recommend to be sent home with its mother on the early discharge plan.

If the feeding is good but not great, continued support in the community by your midwife should be arranged before discharge. A minimum of 2 good breast feeds should occur before going home. The midwife will help you know if the feed was good, which is especially helpful in first time mothers.

Jaundice (“My baby looks yellow in its eyes and skin” Is this normal?”)

Many babies have a yellowish colour of the skin called “jaundice” noted in the first 1-2 weeks of life. It is usually gone after the first month.

Jaundiced is usually noticed in the whites of the eyes (“sclera”), face and may spread to the chest, tummy and legs.

If you, or your midwife (or your doctor doing a new born check) thinks your baby is yellow in the first 24 hours of life, it needs an urgent blood test for a dangerous type of jaundice. You need to wait in hospital until your baby is cleared.

If you have concerns please contact your nominated midwife for a review or advice on getting a blood test.

Heart disease (“Does going home early mean heart disease can be missed in my baby?”)

As mentioned earlier, some cases of heart disease will not be picked up in the first 12 hours of life. This is due to the changes in the blood flowing in the heart and lungs.

If your baby become blue (on its lips, tongue, face and/or body), is having breathing difficulties or is becoming excessively sweaty, they need to be urgently reviewed by a medical practitioner. If all remains well it is important that you child still be reviewed by a medical practitioner within 48 hours.

In hospital we do an oxygen test on the lower leg to check for signs of heart disease.

Wet nappies, wees and urination (“what is the normal amount of wee for my baby? And when?”)

It is recommended that your child has done a wee and poo before going home.

As nappies are so good at mopping up wee, they will feel dry, so it can be hard to know if wee is passed or not. The nappy will be heavier and may change colour with wee in most disposable brand nappies

In the first day babies may not wee much, but by the end of 24 hours your baby should have a wee (“a number by the end of day 1”.

If there is no urine passed after 24 hours, review the feeds for your baby, consider a bottle top up if breast feeding, and we recommend the nurse ask the baby doctor (called a paediatric registrar) to come and examine your baby.

After the first day or two, most babies pass urine 4- 6 times per day, and you will notice this with nappy changes they are wet. If your baby is only doing 1-2 wet nappies per day, discuss this with your nurse.

Poos, bowel motions (“what is the normal colour poo for my baby? How many poos should it do?”)

Babies should past its first pooh within the first 2 days of life. (Baby should “do a number 2 by the end of day 2”)

The first poo is a special, sticky, very dark green pooh called meconium. Once this has passed the pooh changes to a yellowy, brown or sometimes a greenish colour. It should not be red, black, grey or white.

If you think the poo is a funny colour then keep one in a nappy and show your medical staff. Babies’ bowel motions are variable and may range from 4-6 per day to passing one bowel motion every few days.

Sleeping patterns (Is my baby too sleepy?)

Babies are unpredictable in their sleeping patterns. Many babies do sleep a lot in the first weeks of life, and are more wakeful after this.

Some general comments on the sleep/wake cycle.

1) For a least a few times per day and at least a few minutes your baby should wake up, and look at your face and be aware of you. If your baby does not wake up and look at you, you need to get a medical review for too much sleepiness. (Note a review is needed even if your baby was awake in the first day or so and then stops doing this on day 2-3)

2) Even if they are sleepy, babies should be able to wake up to suck for a feed.  

So even if you baby is sleeping for much of the day in the first week of life, if it wakens up for feeds, does plenty of wees and poos, is moving normally crying normally, and is awakening with cares (nappy changes  and baths and getting dressed)- things are probably OK.

But if you are worried about your baby sleeping too much- get a medical examination done.

Serious Infections in babies and GBS

Infection can occur within the first 48 hours of life. This may be due to group B Streptococcus bacteria (“GBS”) a “bug” that may live in the mother’s vagina and unfortunately may infect your baby after birth.

About 1 in 1,000 babies may have this serious bug infection after birth.

We try to reduce this risk by giving mothers antibiotics more than 4 hours before baby is born. This reduces the risk to your baby to a lower amount, roughly only 1 in 100,000 babies will get the GBS infection with their mother treated.

Note if the antibiotics are given “too late”, that is less than 4 hours prior to delivery the risk to baby is roughly increased up to 1 in 1000 babies.

If you have tested positive on you GBS swab test it is advised that you stay for 48 hours (of 24 hours if adequate antibiotics were given). Even if you have a negative swab test there is still a possibility of

Some signs of serious infection in baby

(“How do I know if my baby has a serious bacterial infection? A serious bug”?)

Signs of infection include:

a) Lethargic- your baby may not wake up for feeds

b) Poor feeding- see above Feeding section, and your baby sucks weakly, sucks for a few minutes only, doesn’t finish the bottles)

c) Breath holding episodes (your baby holds its breath for more than 10 and concerningly more than 20 seconds, going pale or blue. attention immediately

d) Shortness of breath- your baby seems to be breathless (head is bobbing up and down, nostrils are flaring, baby may have noisy breathing e.g. grunting)

e) Your baby may feel hot and have a fever more than 38c. We recommend that you have a thermometer to check the temperature under the armpit at home and if it is high, present for a medical review quickly – any time of day or night.

Education:

Before going home it is important that you are understanding of all issues mentioned on this fact sheet. If you have any questions or concerns please make sure you let you midwife know. It is also important to know that you may stay longer to ensure that you are happy with your child before going home.

What next?

-          You will need to see a qualified medical professional within this next 48 hours of going home for a repeat examination and to ensure there is no evident of heart disease

-          Ensure you child is feeding every 3-4 hours (maximum)

-          Ensure your child is behaving normally in the areas above

-          Ensure you have a planned follow up with your midwife

-          Ensure you have a planned medical practitioner review within the next 48 hours

-          Any concerns with infection, feeding, jaundice, sleepiness, breathing difficulties or any other issues please seek urgent medical attention