When a child is in stress from complications from a homebirth, it is crucial to transfer to a local hospital for further treatment. Risks of complications from home delivery can lead to respiratory failure and potential brain injury. The Neonatal Resuscitation Program provides the guidelines of discontinuation of resuscitation after the timeframe of ten minutes. After that time, the absence of heart rate and respiratory effort increases the risk of mortality.
“About 10% of newborns will require some assistance to begin regular breathing, and about 1% of newborns will require extensive resuscitation to survive.” (Neonatal Resuscitation Program 2012)
As for the antibiotics and vitamin K injection which is part of the routine, post-delivery there are mothers refusing to consent to these treatments.
According to Stanford University, the erythromycin ointment and vitamin K injection must be distributed within three hours of birth. Their instructions are as followed, “1. Place 1-2 cm of sterile erythromycin ointment on the conjunctival sac of each eye. 2. Make sure ointment reaches all of the conjunctival sac. 3. After one minute, excess ointment may be wiped away.” (Stanford University) If the parent refused the vitamin K injection they have developed an alternative form. The vitamin is then given orally. The process starts with “2-4mg PL vitamin K after the first feeding then 2mg at 2-4 weeks and again at 6-8 weeks OR 2-4mg PO vitamin K after first feeding then 2mg within first week and weekly while breastfeeding OR 2mg PO vitamin K after first feeding then 2mg within first week followed by 25mcg daily for 13 weeks.” As you can see, the alternate form of vitamin K is a much more timely process and more complicated than the regular, initial injection. 2 – 4mg PO vitamin K after first feeding then 2mg at 2 – 4 weeks and again at 6 – 8 weeks OR 2 – 4mg PO vitamin K after first feeding then 2mg within first week and weekly while breastfeeding OR 2mg PO vitamin K after first feeding then 2mg within first week followed by 25mcg daily for 13 weeks. There is no licensed PO form in US, but parental form can be given orally in countries that have gone to PO prophylaxis, failures (even with good compliance) have been reported. Failures have not been reported with IM prophylaxis. Since multiple doses are required, compliance is an issue advise parents regarding the increased risk of VKDB (exact numbers are unknown) maternal dietary changes have little effect on overall vitamin K status of newborn.” (Stanford Medicine)
After they clean and asses the baby they check their weight and length, clean them up, apply antibiotic ointment on the baby’s eyes and administer the vitamin K injection. The antibiotic ointment that is applied on the eyes is called Erythromycin or Silver Nitrate. The purpose and importance of the ointment is to protect the newborn from infection after coming through the birth canal, vaginally. The ointment can help prevent infections such as conjunctivitis, ophthalmia neonatorum and sexually transmitted diseases. (CDC). Though some mothers refuse it is the law in some states. If the baby is born at home they do not always have the option of erythromycin or the vitamin K injection. Some births centers do offer the erythromycin and vitamin K. However, it is upon request only. If a mother in not familiar with those two treatments they may not be educated by their “home birth” team with the result of no treatment.
These treatments are extremely important and can affect the baby throughout their lives. Mothers should be required to be educated about the treatments and the “home birth” teams must make it mandatory to provide the ointment and injection regardless. On average, the erythromycin ointment only costs three dollars and around forty five dollars for the vitamin K.
When a baby is born their vitamin K level is going to automatically be low of vitamin K-dependent clotting factors and develop an increased risk for bleeding. As adults we are able to receive vitamin K through the leafy, green foods we eat. (CDC)
Infants who do not receive the vitamin K shot at birth are at 81 times greater risk for developing Vitamin K deficiency bleeding (VKDB) than infants who do get the shot. This number is very significant and alarming. VKDB is a life threatening disorder that can develop immediately after birth up to twelve weeks after delivery. There are three categories the bleeding disorder is categorized and developed by the mother taking certain medications that interfere with the vitamin K metabolism. Early (0–24 hours), classical (1–7 days) and late (2–12 weeks). When it is developed immediately after birth it is a result of some medications that are known to contribute to VKDB are anticonvulsants (phenytoin, barbiturates, carbamazepine), antitubercular drugs (rifampin, isoniazid), vitamin K antagonists (warfarin, phenprocoumon).
Classic VKDB generally has symptoms of bruising and bleeding from the umbilicus. The late stags is generally the most concerning and will appear up to six months of age in infants who appeared to seem healthy. Between 30-60% of the “late” VKDB patients, they develop intracranial bleeds which are very life threatening. In most cases of VKDB there are no warning signs that show until the emergent bleeding has begun. Babies who do not receive the injection may show the warnings of, bulging fontanelles, Diffused bruising and ecchymosis, Feeding intolerance, irritabilities, Epistaxis, Jaundice and pallor. (CDC)
Vitamin K is safe and recommended. It can save lives and prevent bleeding disorders. However, there are parents who believe in the myths and misperceptions regarding the vitamin K injection.
This shot has been given and recommended by the American Academy of Pediatrics since 1961. “Without this prophylaxis, incidence of early and classical VKDB ranges from 0.25% to 1.7% of births; incidence of late VKDB ranges from 4.4 to 7.2 per 100,000 infants (1–3). The relative risk for developing late VKDB has been estimated at 81 times greater among infants who do not receive intramuscular vitamin K than in infants who do receive it.” (Morbidity & Mortality Weekly Report, 2013) In 2013 there were four reported cases of late vitamin K bleeding deficiency in a children’s hospital in Nashville Tennessee.
Their coagulopathy test that was performed to show the vitamin K level was greater than or equal to the normal limit. The way this could be corrected was to administer the vitamin K injection. These infants seemed to be in good health and good development until the sudden symptoms. Three of the infants had diffuse intracranial hemorrhage, and the fourth had a gastrointestinal bleed. Of the four cases, the parents had refused the vitamin K injection at their births. Fortunately all four of the infants survived with only one of them showing gross motor deficit. At the Nashville hospital 28.0% of the 218 neonates did receive the Vitamin K injection. When the parents were asked why they refused they stated they did not want extra, unnecessary toxins put into their child’s body and/or were afraid of the possible link of leukemia. The possible link of leukemia was a study done in 1992 but the study has not been persistent and shows no evidence.
Parents need to become more educated on the importance and benefits the injection and antibiotic ointment has on their child. Unfortunately, parents who refuse the treatments that are given at the beginning are most likely to be parents who refuse to vaccinate their children as well.
Erick Gerday MD, is a Neonatologist at Utah Valley Regional Medical Center in Provo. He has been at that hospital for nine years. As he expressed his experience with the vitamin K injection and the erythromycin he said that out of those years at the hospital he believed to only deal with twelve to fifteen parents who refused the vitamin K injection and the erythromycin. The reasoning’s behind them being, they were either not interested in having their child poked, the erythromycin cream wasn’t needed since they had a cesarean section rather than a vaginal delivery, hence they weren’t exposed to the birth canal. And some who were offended and defensive saying they were not “that type of person” who was contaminated with an STD and their child would not need it. As mentioned above, the erythromycin cream acts as a protectant against any possible sexually transmitted disease the mother may carry.
Studies performed in Italy showing which during the neonatal period conjunctivitis occurred in one to twelve percent of all babies. It is the infection that can be given during the delivery through the vaginal canal. The most frequent agents that are involved in the ophthalmia neonatorum infection are the three most common STD’s.
They are chlamydia, gonorrhea and trachomatis. (Ophthalmia neonatorum: what kind of prophylaxis? 2010) “The Committee on Infectious Diseases of the American Academy of Pediatrics publishes data concerning the epidemiology of the phenomenon in the United States. The last available report, published in the Red Book in 2009, notes the following causes: Chlamydia trachomatis (2–40%), Neisseria gonorrhea (51%), Herpes Simplex (51%); other infecting agents (30–50%) (Table I). Besides the infectious forms, ON also includes chemically induced conjunctivitis which occurs in 10–90% of newborns subjected to the prophylactic agent silver nitrate.”
Conjunctivitis, the result of chlamydia will generally develop five to fourteen days after birth and can affect one or both of the eyes. When the prophylactic agent is absent, ranging in thirty to fifty percent of newborns from their infected mother, delivered vaginally. Unfortunately some of these newborns who are exposed to this can develop other health issues as well. Ten to twenty of them contract pneumonia one to three months after they are born which fifty percent of them preceded to conjunctivitis. That being the reason as to why newborns with ON from Chlamydia should be treated systemically with an erythromycin base or etilsuccinato therapy for at least two weeks. The herpes virus (HSV) can also affect the newborn. Often ninety percent of the cases are peripartum by coming in contact with infected areas due to lesions, mucous or other secretions. The neonatal HSV affects the skin, eyes and mouth and will show up between six to fourteen days. If the erythromycin or other eye treatments are not given these side effects can occur as well as blindness. The dosages require one drop per eye which is equivalent to 1/20 ml of ophthalmic solution. The prophylaxis should be readily put to work after the birth. The best prophylactic agents for ON should have the following,
- Precise characteristics
- Should be efficient in protecting the newborn from both N. gonorrhoeae and Chlamydia.
- Should present a low risk in terms of the selection of highly resistant bacterial strains
- Should not cause chemical conjunctivitis
- Should be available in single-dose packaging
- Should be inexpensive (Journal of Maternal-Fetal & Neonatal Medicine)
As the risks are given, the vitamin K and erythromycin application outweigh the risks and complications that can occur if not given to the infant. Risks of infection or disease is very well a possibility. Home births can be successful, but they can also turn direction in a short amount of time as well.
Summary: The risks involved with home birthing should be highly looked upon and truly considered if that is the direction they prefer to go.