In the first hour after birth, while parents are oblivious to everything but their new little miracle, nurses have a lengthy checklist to attend: Measure the baby's weight. Record the pulse. Clean the tiny body. And squeeze a thin ribbon of antibiotic goo across the newborn's eyes.
That bit of goo, called erythromycin ointment, is now at the heart of a debate between Erlanger Health System officials and bedside caregivers like nurses and midwives, who worry that a newly tightened policy on the ointment could pit them against parents in a delivery room battle.
The key question: Where does the buck stop when it comes to a newborn's care: The parents, the hospitals or a 100-year-old law?
Erythromycin protects babies' eyes against infections they can acquire in the birth canal if the mother has a sexually transmitted disease such as gonorrhea or chlamydia. Such infections can lead to blindness, and since 1915 Tennessee law has required protective ointment be applied within an hour after birth -- no exceptions. Georgia requires the same thing.
Doctors say the ointment is effective and without side effects. However, a few parents are refusing the ointment. Some insist they don't have STDs, and so the ointment is unnecessary and unnatural. Others say the procedure interferes with critical bonding during their child's first moments of life.
Traci Josephsen, clinical resource specialist for women and infant services at Erlanger, said fewer than one parent a month refuses the ointment. But, unlike vaccinations and newborn screenings, state law provides no exemptions. So when parents refuse it, hospitals face a dilemma: Respect parents' wishes and break the law? Or go against a parent's will?
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Starting this year, Erlanger has opted to stick to the letter of the law. The new policy requires nurses to administer the ointment no matter what -- even if it means calling security to intervene if parents object.
In years past, parents who refused the ointment signed a form saying they had been informed of the risk, and hospital officials reported that to the Department of Children's Services. But after one baby was not given the ointment late last year, hospital officials decided the policy needed to be clearer and stricter.
Josephsen said the change protects doctors and nurses from lawsuits or the Class C misdemeanor penalty attached to the law.
"I can't speak for our lawmakers [who wrote the law], but I believe that their intentions were to protect the child," she said. "And the law is very clear that it's doctors and nurses who are responsible to do that. ... We don't want to go against a parent's wishes. But when it's the parent's wishes versus the law, we have to go with the law."
Now, if a parent refuses to apply the ointment, a new protocol is set into motion. Doctors must speak with the parents, and risk management attorneys may become involved. If parents still refuse and a nurse is unwilling to go against their wishes, another nurse or doctor must be found to perform the task.
"If parents continue to refuse application of ointment, call security and administer the ointment with security at the bedside," the policy states.
Josephsen said such a measure would only be taken "to protect the nurse," and it has not been needed so far.
But one Erlanger East labor and delivery nurse, who asked not to be named because she does not have authorization to speak on the matter, said for her and her co-workers, the policy "goes against everything" she has been taught about patients' right to refuse treatment.
"You're darned if you do, darned if you don't," she said. "If we don't, then we could supposedly get sued. If we go through with it, then I'm afraid someone could say it's battery because we're providing care against their wishes. That's my biggest fear."
She said she would not go against parents' wishes, even if a security guard was involved.
Local midwife Amy Miller Anderson, who has worked in labor and delivery for more than 20 years including her time as a nurse, said the policy has "deeply troubling" implications.
She does not discourage the use of erythromycin ointment, and always spells out what the law requires.
"What I don't agree with is the use of force. ... It's entirely inappropriate," said Anderson.
How the law is meant to be enforced is unclear. State health officials have no record of a medical professional being prosecuted for failing to follow the statute. Tennessee Department of Children's Services spokesman Rob Johnson said officials have never had to intervene in such a case. And Dr. Michael Warren, assistant state health commissioner with the Division of Family and Children's Services, said state health officials do not track hospital policies or how often parents opt out of the treatment.
When the issue arises at Parkridge Health System, physicians usually sit down with parents, said Jerri Underwood, chief nursing executive.
"Education has had great success in gaining parents' acceptance," Underwood said. She did not say what would happen if parents refused treatment, but added she has seen ointment applied against a parent's will.
Monroe Carell Jr. of Children's Hospital at Vanderbilt in Nashville requires parents to sign a form saying they understand the risk of refusal, said spokesman Matt Batcheldor.
At Memphis-based Baptist Memorial Health Care System, officials say parents could sign a form to refuse the ointment.
At Erlanger, Josephsen said she knows of two mothers who initially declined the ointment since the new policy was put in place in January. They both ended up consenting after talking with doctors, and security was never called.
The hospital is trying to make sure the issue is addressed before babies are born. But the best thing that detractors can do, she said, is go to their legislator and ask them to change the law.
Anderson has already begun to do that.
"There has just got to be a better way to handle this issue," she said.
She has spoken with Sen. Bo Watson, R-Hixson, who told the Times Free Press he was asking for information from state health officials and was open to "seeing if we need to tweak this law."
"If policies run the gamut, and if this looks like something where parents have no choice, it begs the question -- is this something legislators should revisit?"
Contact staff writer Kate Belz at firstname.lastname@example.org or 423-757-6673.
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