Evaluation by a perinatalogist and/or hospital transfer is indicated in the event of an extremely difficult labor or birth, a severely depressed, ill or injured baby, one suffering from a significant congenital anomaly or any baby for whom the parents are concerned and request hospital care. This category is fairly easy to identify.

However, community midwives sometimes find themselves caring for babies with transient problems of mild to moderate severity which have stabilized or are resolving and thus do not appear to warrant immediate medicalization. Other factors that enter into this decision are families that live in remote or rural locations with long travel distances to appropriate medical services, those living in locations where the services of perinatologists are not available, those with no healthcare insurance or MediCal coverage and parents who decline prophylactic medical care for religious reasons. In these situations additional observation, monitoring, parental instruction, recommendation of a pediatric exam (informed consent/decline for parents who decline to have the baby examined by a physician) are indicated.

Examples of transient problems include mild to moderate episodes of bradycardia or tachycardia during labor followed by good recovery with continued normal FHT variability, unexpected appearance of thick meconium at the time of the birth, shoulder dystocia that is protracted or requires significant manipulations, any baby requiring resuscitative procedures at birth beyond a few puffs of positive pressure ventilation (prophylactic PPV for a "slow starter" -- 6 or less assisted respirations during the first 30-40 seconds or blow-by O2 which can be discontinued in less than 30 minutes is generally associated with benign situations).

Even babies without identifiable stressors can be mildly depressed at birth and may take up to an hour to "normalize" at an optimal level. Benign conditions which are stable or improving are usually accompanied by improving apgars. During first hour after the birth the midwife is actively observing the baby, noting color, vigor, respiratory and heart rate and ability to nurse so more latitude can be taken during this period of intense observation. By the end of the first hour most healthy babies will have an apagr of 9 or above. Observation for at least 2 hours by the midwife or a trained assistant is appropriate for all newborns, longer if any subtle signs of distress are present.

Not all problems automatically resolved simply by the successful passage of the first hour. Babies with mild meconium aspiration syndrome look very good immediately but about an 1 hour after the birth tends to develop signs of respiratory distress (increasing respiratory rate (>> 90+), grunting, flaring of nares, pallor, central or circumoral cyanosis, poor muscle tone, inability to nurse, etc).  A community midwife in Alaska reported a postnatal death from meconium aspiration syndrome at 8 hours after birth.

If there are continuing questions of neonatal wellbeing the midwife or another qualified observer should watch the baby for the first 4 to 8 hours and transport the baby if it does not maintain an essentially normal profile with normal vital signs. Prolonged observation can be provided by parents or another adult familiar with infant behavior (grandmother, etc) who agrees to remain awake, can demonstrate their ability to count the baby’s respiration and heart rate, and who has been given very specific guidelines on what to watch for and when to call the midwife or medical careproviders. Observation by another adult allows the midwife to nap for a few hours at the parents home with instructions to be immediately awakened if there is a question about the baby’s condition. If no one is able to provide this extended observation the parents should be advised to take the baby to a perinatalogist or other physician for an evaluation.

Profile of a healthy baby includes:

Normal newborn exam with heart rate between 110 - 150, no heart murmurs, clear lungs, abdomen soft w/o masses, respiratory rate between 40 and 70, reasonable muscle tone (normal arm recoil as used in Dobowitz Gestational Age Assessment), no central  or circumoral cyanosis and a regular respiratory pattern without persistent grunting, flaring of nares, retracting, sea-saw breathing, signs or symptoms of circulatory insufficiency, signs of seizure activity or lethargy (inability to wake baby or trigger crying).

Be particularly watchful of babies with a cluster of several small or subtle abnormalities that would not be of great concern if they were a single isolated finding. For instance, TTN (transient tachypnea of the newborn) in a baby with no risk factors, nursing well and all others parameters WNR is far less worrisome than a baby with a known risk factor (stressful birth, lower apgar, mec, etc) and a cluster of mild abnormalities such as slightly raised respiratory rate, slight pallor, a bit floppy, mild grunting and won’t nurse. Pulse oximetery would be useful equipment in these situations.

Instructions to parents before the midwives leave the parent's home:

Community midwives should recommend that parents immediately contact the midwife or arrange for physician evaluation of their newborn should they observe any potential problem, such as poor color, weak cry, lethargy, respiratory difficulty, etc. Parents should be instructed to take their baby to the emergency room if unable to contact the midwife or a doctor for more than one hour. They should be instructed to call paramedics if the baby’s condition seems extremely serious, such as a baby with central cyanosis or erratic respiration or any bleeding or loss of consciousness.

Use of the "Nativity Card" as developed by the ACDM (or similar record) is recommended to assist interface with perinatal or pediactric careproviders. On the back of the card are instructions for parents listing the most common newborn problems and their danger signals and emphasizing the central role parents play in safeguaring the newborn as nobody spends more time with their baby or cares more for its wellbeing than do they.

In particular it is useful to emphasize to parents that when the midwives leave the parents will need to take over the responsibility of determining if or when medical services are indicated. While they may call the midwife to solicit advise, she cannot see the baby or examine it over the phone. Parents should be encouraged to act on any "intuition" or premonition by seeking out physician care, even if it is inconvenient or they do not have health insurance. It is better to be safe than sorry.