HYPOGLYCAEMIA and newborn babies

From time to time I have an opportunity to participate in a Baby Friendly Health Initiative (BFHI) assessment of a maternity hospital.   I have participated in BFHI since the early 1990s. Today I am reflecting on one such recent assessment, and the importance of protecting, promoting and supporting breastfeeding.

BFHI is a global initiative of WHO and UNICEF. Hospitals implement infant feeding policies consistent with the 'Ten Steps to Successful Breastfeeding', and ethical marketing practices for the distribution of artificial milk formulas for babies.

Hypoglycaemia (low blood sugar) is the *diagnosis* under which many breastfed babies in Australian hospitals receive formula feeds in the first hours of their lives. Babies of mothers with poorly managed diabetes - that is, mothers whose blood sugar levels are abnormally high - can become very ill very quickly when their sugar supply is abruptly cut off at birth. Please refer to the Women's hospital CPG on infant management of Hypoglycaemia 1. for further review of definition and management guidelines. The brief comments I wish to make in this post will be made with consideration of that CPG as a statement of the way I understand contemporary practice.

Definition of terms

Hypoglycaemia: There is a lack of consensus on a definition of neonatal hypoglycaemia. It is recommended that clinical practice be guided by operational thresholds (i.e. blood glucose levels at which clinical interventions should be considered). Clinical signs which suggest clinically significant hypoglycaemia are non-specific and include jitteriness, irritability, high pitched cry, cyanotic episodes, apnoea, seizures, lethargy, hypotonia or poor feeding.

When BFHI assessors visit a hospital, we have a series of questionnaires that are designed to gauge the hospital's compliance with the global BFHI criteria. Midwives, doctors, and other staff who advise women on breastfeeding are asked to state three acceptable medical reasons for use of breastmilk substitutes. The usual response includes 'hypoglycaemia'. The assessor is required to explore the meaning of 'hypoglycaemia' further to check if the staff member is confident of what is an acceptable reason.

The BFHI acceptable medical reasons include

• newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age, or who have experienced significant hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic) if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.

Usually the hospital's own clinical practice guidelines will be quoted. The assessor is able to then check the hospital's guideline on management of babies with hypoglycaemia. 

Why is this important?

The short answer:  Diabetes.


A longer (incomplete) answer:
'Hypoglycaemia' is one of the main reasons for breastfed babies in hospital receiving formula feeds.  Diabetes and hypoglycaemia are closely linked, and breastfeeding may prevent the development of diabetes later in the child's life.

A hospital that has a breastfeeding policy consistent with the BFHI '10 Steps to successful breastfeeding' is required to implement management guidelines for hypoglycaemia that are consistent with the breastfeeding policy. The 'steps' in which a hospital's management of suspected hypoglycaemia has a potential to interfere with the establishment of breastfeeding are:

Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff

"exclusive breastfeeding in the first six months of life

• protects against chronic conditions in the future such as type-1 diabetes, ulcerative colitis and Chron's disease

Breastfeeding during infancy is associated with

• ... lower prevalence of type-2 diabetes, overweight and obesity during adolescence and adult life
  ..." [from BFHI Australia Booklet 1, p16]

Step 2: Train all healthcare staff in skills necessary to implement this policy

Protecting, promoting and supporting the natural physiological processes in birth and nurture of a baby requires skill and commitment by all care providers.

 
Step 3: Inform all pregnant women about the benefits and management of breastfeeding

Women who are well informed will be able to make informed decisions about any interventions that are recommended in the care of themselves or their babies.  Those who know they are at risk of having babies who develop hypoglycaemia are able to take some measures to avert the need for breastmilk substitutes, including careful dietary measures and avoidance of sugary foods.

Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.

The hospital's definition of 'medically indicated' must be consistent with the BFHI acceptable medical reasons.  Also, note the need for true blood sugar level to confirm hypoglycaemia.

Step 7: Practise rooming-in - allow mothers and infants to remain together 24 hours a day

Babies identified as 'at risk' who are asymptomatic should stay close to their mothers and breastfeed normally. 

• infant with risk factors for hypoglycaemia but no clinical signs - blood sugar level < 2.0 mmol/L [Women's CPG]

Step 8: Encourage breastfeeding on demand


Step 9: Give no artificial teats or dummies to breastfeeding infants

The hospital policy and guidelines need to be reviewed critically at regular intervals, by people who are well informed and who are skilled at asking good questions.  

The protection of breastfeeding in potentially complex clinical situations is not a yes-no, black or white situation.  Guidelines can, and often do, help us to avoid unnecessary and potentially harmful interventions into normal physiological breastfeeding situations.

For example, a baby weighing 4 Kg at birth may in some cases be at risk of hypoglycaemia, and in other cases be healthy, consistent with the size of his or her parents and siblings.  In the latter case a clinical judgment would be made by the midwife, not to measure blood glucose levels as this baby is judged to be a well, term infant.


Thankyou for your comments

A letter to obstetricians

I have sent letters to obstetricians practising in my area.

Re: Medicare rebates for private midwifery services

Dear Dr XXXX
I am writing to inform you of my current private midwifery practice since obtaining notation as a Medicare ‘eligible’ midwife. 

Examples of the services I am able to provide are:
• a part of the woman’s care such as postnatal only (after discharge from hospital)

• antenatal care that is shared with an obstetrician or hospital,
• primary maternity care for the whole episode of care, whether the woman is planning to give birth at hospital or in the home.
[Note: At present midwives do not have visiting access/clinical privileges in hospitals. However, this is a goal to which public hospitals are working, through the Three Centres group project on ‘Collaborative arrangements with eligible midwives for Victorian public hospitals’. I am a member of the Expert Reference Group for this project, and am keen to see privately practising midwives able to obtain visiting access in hospitals.]

Medicare scheduled fees and rebates for private midwifery services are listed on the attached document Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011.

Since becoming eligible for Medicare, I have found that some women appreciate more postnatal visits in their homes, with Medicare rebates making the service more affordable, than was previously the case. Rebates are available for postnatal consultations in the six weeks following the birth, and for a 6-7 week review. I am now able to write referrals to obstetricians and paediatricians, and request tests and investigations related to childbirth. I do not yet have PBS authorisation, and Victorian law is yet to be amended to enable midwives to prescribe.

In order for women to claim Medicare rebate on fees for antenatal and postnatal visits the participating midwife is required to document a collaborative arrangement, by which a specified medical practitioner is identified as the person to whom the woman will be referred if indicated. Referral is one type of collaborative arrangement, described in Section 5(1) that the “patient is referred, in writing, to the midwife for midwifery treatment”, in this case antenatal and/or postnatal services, and that [Section 5 (2)]: “For subsection (1), the arrangement must provide for: (a) consultation between the midwife and an obstetric specified medical practitioner; and (b) referral of a patient to a specified medical practitioner; and (c) transfer of a patient’s care to an obstetric specified medical practitioner.”

That is, the collaborative arrangement to be entered into is that I, the midwife, will provide midwifery services (treatment), with consultation and referral to you when/if indicated. Under such collaborative arrangement, I am required to send you (the named medical practitioner) a Maternity Care Plan (proforma attached), results of any tests and investigations, and referrals.

Also I am required to send a discharge summary to you and the patient’s GP.

I would appreciate your support through referral or other collaborative arrangements. I am happy to make an appointment to meet with you and discuss this with you further if you wish.

There is a small number of midwives in Victoria who now have Medicare provider numbers, and others who are waiting for their applications to be processed. I anticipate gradual expansion of private midwifery services in response to the government’s maternity reforms.

Thankyou for considering this request.
With best regards
Joy Johnston

Attachments: 
Health Insurance (Midwife and Nurse Practitioner) Determination 2010
Maternity Care Plan proforma

When women choose maternity options against the recommendations of their midwife

Having written a post on the new ACM Position Statement on Homebirth Services 2011, together with a 'guidance' document and literature review, for the APMA blog yesterday evening, I find that my mind is dwelling on the situations in which women "choose a planned homebirth when this is not recommended by a health care provider."

What are the forces that are exerted within our communities, pulling women, and midwives, toward professionally acceptable standards and actions?

How does a midwife make a clear and timely call, telling the woman who has employed her to provide homebirth services, that homebirth is no longer recommended?

Where is the cut-off, between low- and high-risk? 



The ACM National Midwifery Guidelines for Consultation and Referral (ACM Guidelines 2008 - which are available to download free as a .pdf) set out situations in which a midwife is expected to consult with, and refer a woman to, an appropriate medical/obstetric service provider.  Conditions listed under category C, requiring referral, include chronic hypertension, pre-eclampsia, multiple pregnancy, breech presentation at Term, coagulation disorders, diabetes requiring Insulin treatment, and many other medical and obstetric conditions and complications that may co-exist with the pregnancy, or arise during pregnancy, birth, or the postnatal period.  A woman experiencing these complications requires coordinated maternity care from a team of medical, midwifery, and possibly other disciplines.

Another all-too-common-today situation is a woman who has had caesarean surgery for one or more previous births.  According to the ACM Guidelines (2008), previous caesarean is category B, meaning that the midwife is required to facilitate consultation with a medical or other health care provider.  The ACM Guidelines do not attempt to differentiate between those for whom homebirth is not recommended. 

The South Australian Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 recommendations state clearly that "A previous caesarean section and breech presentation are contraindications for home birth."

As noted at the APMA blog, obstetrician Andrew Pesce has given advice on a way forward for those who want to bring homebirth into mainstream maternity care, with:

"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."

  

It's clear to me that there are important conversations that the midwife needs to take responsibility for, when complications or new risk factors are identified.  The midwife's professional duty of care requires that the situation, and a plan of action, be clearly outlined and any questions responded to, to the best of the midwife's ability.   The woman's response can be to agree, to disagree, or to explore further.  Simple questions that I encourage women to ask, if at any time someone wants to interrupt the physiological processes are:

• What do you want to do?
• Why do you want to do that?
• What is likely to happen if I say "no"?

The partnership between a midwife and a woman requires honesty and trust both ways.  A woman who fears that her midwife may 'make' her transfer to hospital, for some trivial reason, will not make an informed decision.  Similarly a woman who takes no responsibility for her own decisions, but puts herself meekly in the hands of her midwife, is not making informed decisions.  Trust always has limits.  Midwifery is not a cult; midwives can not ask for blind acquiescence.

As a wise colleague put it,  

"I find the 'trust birth' claim far too naive ... but I think a lot of women in their bubble want to believe it. Perhaps all our easy access to IT - internet/emailgroups/facebook etc has something to do with which women choose homebirth now and why and who and how cult followings get supported, possibly blindly."

I wonder today if some women are misusing maternity care, and abusing the trust of their midwives, in a cult-like way that over-rides partnership, and puts the woman's experience first and foremost. 

 

Thankyou for your comments

Learning Medicare

My mind has been challenged recently as I have attempted to learn the technology associated with Medicare rebates.

I decided that a portable EFTPOS machine would be the best means of processing bulk billing and client rebates through Medicare.  This process requires a lot of technical support - well beyond my skill. The bank sent the machine, and set it up for me. 

The next step was for Kirsty, a lovely lady who works for Medicare, to enter my provider number, and the item numbers for my work.  Kirsty worked through it with me, and I watched her process one claim, then did one myself.  Those payments have now shown up on the bank account statement.

Yesterday I took the machine to a postnatal visit, and attempted to process the bulk bill payment on the spot.  It didn't work.  I obtained a signed authorisation from the client, determined to work it out.

Today I opened the manual, followed multiple instruction steps, and identified the point at which I had been stumped.  I was able to complete the transaction.  YAY!


Medicare has offered me the immediate opportunity to do more postnatal work for my clients.  This is great.  I am thankful.