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 Table of Contents  
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 130-133

Managing extramural neonates: Experience from a zonal hospital

1 Department of Paediatrics, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Paediatrics, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission30-Jan-2019
Date of Acceptance17-Jul-2019
Date of Web Publication07-Oct-2019

Correspondence Address:
Surg Capt (Dr) Ranjeet Wishram Thergaonkar
Department of Paediatrics, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_6_19

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Introduction: There are many challenges in the care of extramural neonates (born outside the hospital), especially in resource-limited secondary care (zonal) hospitals of the Armed Forces. The objective of the present study was to describe the workload and complications faced in the care of extramural neonates in a zonal hospital of the Armed Forces. Subjects and Methods: The study design was descriptive. The setting was a 306-bedded zonal hospital. Records of all neonates transferred from other hospitals between January 1, 2017 and December 31, 2017 were studied. Median and interquartile range of continuous data, as well as the number and percentages of ordinal data, were calculated. Results: Seventeen neonates (10 males) were received from a median distance of 70 km. The workload comprised 539 patient-days and 12.4% of the nursery workload. The extramural neonates included 2 (11.8%) extremely low birth weight (<1000 g), 6 (35.3%) very low birth weight (1000–1499 g), and 4 (23.5%) low birth weight (1500–2499 g) babies. Thirteen (77.4%) neonates were lateral referrals from private nurseries. The complications included hypothermia in 4 (23.5%), hypoglycemia in 3 (17.6%), and sepsis in 8 (47.1%) neonates. One (5.9%) baby died after admission. Conclusions: Extramural neonates constitute approximately 12% of the nursery workload. High number of low birth weight babies, lateral referrals from other neonatal intensive care units, relatively lower but significant rates of hypothermia and hypoglycemia, high rate of sepsis and low mortality highlight the management of extramural neonates in a zonal hospital.

Keywords: Extramural, neonate, secondary care

How to cite this article:
Bhat V, Thergaonkar RW. Managing extramural neonates: Experience from a zonal hospital. J Mar Med Soc 2019;21:130-3

How to cite this URL:
Bhat V, Thergaonkar RW. Managing extramural neonates: Experience from a zonal hospital. J Mar Med Soc [serial online] 2019 [cited 2022 Aug 12];21:130-3. Available from: https://www.marinemedicalsociety.in/text.asp?2019/21/2/130/268627

  Introduction Top

The challenges in the care of an extramural neonate are many. The important ones include no opportunity to advise antenatal intervention, incomplete availability of antenatal and family history at admission, loss of time and physiological instability inherent to transport and carriage of pathogens, often multidrug resistant, from units where the neonate has been previously admitted. Consequently, it is more common to face complications such as hypothermia, late-onset sepsis, necrotizing enterocolitis, intraventricular hemorrhage, higher ventilatory requirements, longer duration of hospital stay, and higher mortality in extramural neonates.[1]

Secondary care (zonal) hospitals in the Armed Forces are often constrained to provide clinical services in keeping with the authorized sanction of facilities, workforce, and equipment.[2] Extramural births are not naturally factored in when scaling. In addition to routine indications for transfer,[3] hospitals in the Armed Forces often receive neonates referred for reasons such as financial or due to the transfer-in of a high-risk mother. To the best of the authors' knowledge, no study has examined the workload and complications posed to hospitals of the Armed Forces by extramural neonates.

This study is aimed to describe the workload, clinical concerns, and complications faced in the care of such babies in a zonal hospital of the Armed Forces.

  Subjects and Methods Top

This is an observational study for data collected retrospectively from January 1, 2017 to December 31, 2017. The setting of the study was a 306-bedded zonal service hospital. The pediatric ward has 21 laid-out beds and a 5-bedded neonatal intensive care unit (NICU). The ward includes a single-bedded high dependency unit (HDU) with a radiant warmer and also a step-down neonatal care unit (SDU). The pediatric ward and the NICU are manned at any given time by at least one staff nurse each. The entire complex is provided specialist cover by 1–3 pediatricians at any given time without any resident doctors. In the year of the study, one pediatrician was a qualified neonatologist. The number of deliveries in the hospital in 2015, 2016, and 2017 was 1166, 1200, and 1117, respectively.

The location to which an extramural neonate is received is decided based on the protocol outlined in [Figure 1]. A blood culture is performed for all sick extramural neonates at arrival. Empirical antibiotic therapy, if initiated in the previous hospital, is continued till a 48-h negative blood culture report is received, and the baby becomes asymptomatic.
Figure 1: Protocol for receiving an extramural neonate

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The information extracted with respect to the subjects from case records was status at admission, gestational age, birth-weight, age in completed days of life on arrival, sex, type of referring hospital, details of previous admission (s), distance from referring hospital, notification from referring hospital prior to transport, discharge summary, means of transport, therapy during transit and requirement of resuscitation at arrival, details of treatment and course, mortality and length of stay at our hospital.

Median and interquartile range of continuous data, as well as the number and percentages of ordinal data, were calculated using Microsoft Excel 2016.

  Results Top

Details of extramural neonates are presented in [Table 1]. A total of 17 extramural neonates were managed during the study, comprising 12.4% of 137 nursery admissions in the year. The gestational ages of the neonates ranged from 29 to 39 completed weeks. The birth weights ranged from 800 to 3700 g. Two (11.8%) babies were extremely low birth-weight (<1000 g), 6 (35.3%) babies were very low birth weight (1000–1499 g), and 4 (23.5%) were low birth-weight (1500–2499 g) as per standard definitions. The babies were brought to the hospital from day 1 to 28 of life.
Table 1: Details of extramural neonates

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Eleven babies were brought from private NICUs, two babies were self-referred after discharge from private NICUs and subsequent deterioration, three babies were referred by NICUs of government hospital whereas one baby was referred by a private maternity home. Of the eleven babies brought from private NICUs, four had received ventilatory support at the previous hospital; three of these had been administered a single dose of surfactant at the previous hospital. Six babies had been administered antibiotics for clinical suspicion of sepsis at the previous hospital. Two (11.8%) babies had been transferred to the previous hospital from the nursing home/maternity hospital where delivery had occurred, thus making ours the third hospital receiving them. Prior intimation regarding referral in the case of the six babies was received from private NICUs by the baby's relatives/father carrying an abbreviated case summary. In response to this, liaison had been made with the private hospital to ensure the safe transfer of the baby when stable at a mutually convenient time. The discharge summary from the referring hospital for all 12 babies included date and time of birth, date and time of admission and discharge, gestational age, mode of delivery, birth weight, details of resuscitation, working diagnosis, investigations, and treatment details including time of the last administered doses.

All babies arrived by ambulance: in 10 cases, this was arranged by the referring hospital while parents had to organize this in the remaining cases. At arrival, of the seven babies on oxygen therapy in the ambulance, one baby's transfer had been affected by the interruption of oxygen. The baby had been transferred without prior intimation in a state of refractory septic shock from a distance of 70 km without oxygen en route. At arrival, the baby was moderately hypothermic, hypoxic, in shock and required resuscitation including endotracheal intubation. This baby died within 12 hours of arrival. No baby received invasive or noninvasive mechanical ventilation during transfer. Of the four babies, who were hypothermic at arrival, two were noted to be in cold stress (axillary temperature 36°C–36.4°C) and two had moderate hypothermia (axillary temperature 32°C–35.9°C). Of the three hypoglycemic babies, two had suffered from symptomatic hypoglycemia in the form of seizures in the previous hospital but had been transferred without an ongoing glucose infusion.

Of the seven babies managed in HDU, five could not be received in the SDU because of the need for intensive care in the HDU while the others were received in the HDU for lack of space in the SDU. In 8 (47.1%) babies, there was clinical or microbiological evidence of sepsis. This included all six babies treated for sepsis in the referring hospital. Microorganisms isolated were coagulase-negative Staphylococcus in two and Candida species in the other two babies. Two babies required endotracheal intubation and mechanical ventilation after admission, while three were managed with noninvasive ventilation. Workload due to extramural neonates was 539 patient-days.

  Discussion Top

In this study, we share our experience of 17 extramural neonates received over a period of 1 year comprising 12.4% of the nursery workload.

As of 2015, 19% of deliveries in India take place without skilled birth attendants and 13% of deliveries are preterm.[4] In addition, it is estimated that 0.5%–1% of all neonates worldwide suffer from significant asphyxia.[5],[6] In India, a large number of neonates will require transport to a hospital where appropriate care is provided. As per the report of the Ministry of Health and Family Welfare on Care of Small and Sick Neonates in Special Newborn Care Units (SNCUs), 2013–2015, 39% of SNCU admissions were outborn.[6] We report 12.4% of the nursery workload as extramural. This relatively low figure is possible because of a large spread of the population dependent on the hospital, the entitlement for admission, and the difficulties posed by transfer. This nevertheless poses logistic challenges since these babies are managed in a different unit with different protocols and have the potential of deteriorating during transfer.

We noted birth weight <2500 g in 12 (70.6%) neonates. Dalal et al. in their study of 300 extramural babies report low birth weight in only 6% of babies.[7] We noted that 14 (82.4%) neonates were lateral referrals from other NICUs rather than referrals from centers with lesser capability as reported in the studies of Dalal et al., Aggarwal et al., Mathur et al., and Rathod et al.[7],[8],[9],[10] The most likely reason for such transport is unaffordable out-of-pocket expenditure. Since neonatal transport is a risk, it is important to reduce such transport. This may be affected by improved maternal awareness to prevent untimely delivery, improved transport in utero and facilitation of reimbursement of expenditures in these hospitals where justified. We also noted with concern that only 6 (35.3%) neonates arrived with prior intimation. Prior intimation was also noted by Dalal et al. in 28% of extramural neonatal admissions.[7] A neonate arriving without prior intimation precludes prior preparation of a proper station and reduces the possibility of being received by a pediatrician since zonal hospitals do not have residents. Communication within professional bodies may mitigate this problem.

Hypothermia, as noted on arrival in 4 (23.5%) neonates in our study, is a serious concern. However, this was lesser than hypothermia reported in as many as 55% neonates by Dalal et al.[7] and in 76% by Rathod et al.[10] in their study of 303 extramural neonates. This could be due to the higher environmental temperatures in our place of study. Similarly, the incidence of hypoglycemia in 3 (17.6%) neonates in our study is lesser than figures of 20.6% reported by Dalal et al.[7] but more than the figure of 10% reported by Rathod et al.[10] This variation may be due to a different profile of patients, i.e., a high number of low birth weight babies but the majority being referred from other NICUs after stabilization. The physiological stress posed to a neonate by hypothermia and hypoglycemia is considerable, and therefore, these figures are significant.

Seven (40.2%) babies were managed in the HDU, a part of the ward that is not optimized for the care of a sick neonate and fraught with chances of nosocomial infection. Evidence of sepsis was noted in as many as 8 (47.1%) extramural neonates. Neonatal transport is associated with a greater chance of sepsis, as noted by Khinchi et al.[11] This highlights the need for having earmarked infrastructure and separate nursing for extramural babies to prevent cross-infection among extramural and intramural neonates.

Finally, we report low mortality (1/17, 5.9%) as compared to 23.7% by Dalal et al., 43% by Aggarwal et al., and 20% by Rathod et al.[7],[8],[10] This is possible because of stabilization prior to transport at least in babies referred from other NICUs and protocol-based management in our unit under the care of a neonatologist.

Our study is modest in sample size; hence, intense statistical analysis is not possible. However, the study reports experience in an area of importance, i.e., the management of extramural neonates in a zonal/secondary care hospital. This is important in drafting policy, allocating resources, and evolving clinical protocols for the care of these babies.

  Conclusion Top

Extramural neonates constitute approximately 12% of the NICU workload. High number of low birth weight babies, lateral referrals from other NICUs, lower rates of hypothermia and hypoglycemia, high rate of sepsis, and low mortality are the highlights of the experience of managing extramural neonates in a zonal hospital.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sehgal A, Roy MS, Dubey NK, Jyothi MC. Factors contributing to outcome in newborns delivered out of hospital and referred to a teaching institution. Indian Pediatr 2001;38:1289-94.  Back to cited text no. 1
Standing Committee on Defence. Provision of Medical Services to Armed Forces Including Dental Services. New Delhi: Lok Sabha Secretariat; 2017. p. 82.  Back to cited text no. 2
Ministry of Health & Family Welfare, Government of India. Facility-Based Newborn Care Operational Guidelines. New Delhi; Ministry of Health and Family Welfare, Government of India; 2011. p. 84.  Back to cited text no. 3
Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000-15: An updated systematic analysis with implications for the sustainable development goals. Lancet 2016;388:3027-35.  Back to cited text no. 4
Singh M, Deorari AK, Khajuria RC, Paul VK. A four year study on neonatal morbidity in a New Delhi hospital. Indian J Med Res 1991;94:186-92.  Back to cited text no. 5
Ministry of Health and Family Welfare, Government of India. Care of Small and Sick Newborns in Special Newborn Care Units (SNCUs) of India, Two-Year Report April 2013-March 2015. New Delhi; Ministry of Health and Family Welfare, Government of India; 2016. p. 140.  Back to cited text no. 6
Dalal E, Vishal G, Solanki D. Study on neonatal transport at tertiary care centre. Int J Sci Res 2013;2:289-92.  Back to cited text no. 7
Aggarwal KC, Gupta R, Sharma S, Sehgal R, Roy MP. Mortality in newborns referred to tertiary hospital: An introspection. J Family Med Prim Care 2015;4:435-8.  Back to cited text no. 8
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Mathur NB, Krishnamurthy S, Mishra TK. Estimation of rewarming time in transported extramural hypothermic neonates. Indian J Pediatr 2006;73:395-9.  Back to cited text no. 9
Rathod D, Adhisivam B, Bhat BV. Transport of sick neonates to a tertiary care hospital, South India: Condition at arrival and outcome. Trop Doct 2015;45:96-9.  Back to cited text no. 10
Khinchi YR, Kumar A, Yadav S. Profile of neonatal sepsis. J Coll Med Sci Nepal 2010;6:1-6.  Back to cited text no. 11


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  [Table 1]


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