CHHS16/052

Canberra Hospital and Health ServicesClinical ProcedureCare of the Well Baby (Excluding Neonatal Intensive Care Unit and Special Care Nursery)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Alerts.........................................................................................................................................2

Section 1 – Admission...............................................................................................................3

Section 2 – Care of Qualified Babies.........................................................................................3

Section 3 – Monitoring the baby’s health and well-being.........................................................5

Procedure: as per Attachment 3: Guide to Feeds and Output of Babies...............................5

Section 4 – Care of the Small Baby............................................................................................7

Section 5 – Weighing of Babies.................................................................................................9

Implementation...................................................................................................................... 10

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 11

Definition of Terms................................................................................................................. 11

Search Terms.......................................................................................................................... 12

Attachments............................................................................................................................12

Attachment 1: Newborn Status Flowchart..........................................................................13

Attachment 2: Discharge Summary Responsibility for Qualified Babies.............................14

Attachment 3: Guide to feeds and output of babies...........................................................15

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Purpose

To provide a guide for the admission and care of babies to the antenatal and postnatal wards at Canberra Hospital (excluding babies admitted to the Neonatal Intensive Care Unit, [NICU] or Special Care Unit [SCN]).

Scope

This document applies to: Medical Officers Midwives and Registered Nurses who are working within their scope of practice (Refer

to Scope of Practice for Nurses and Midwives Policy) Student Midwives/Registered Nurses under direct supervision.

Scope

Alerts

If a baby demonstrates any of the following, they may need to be reviewed by an experienced midwife or lactation consultant, for the purpose of assessing weight and devising a feeding plan to maximise oral intake and improve the mother’s lactation: Positioning and attachment difficulties when breastfeeding decreased urinary output as per number of days since birth decreased stools or persistent meconium 3 days post birth excessive feeding cues sleepiness, or a jaundiced appearance.

Babies who weigh less than 2000 gms, or are less than 36 weeks gestation at birth, should initially be admitted to the Special Care Nursery (SCN). They may be transferred to the ward from NICU/SCN at less than 2000 gms or 36 weeks when they are able to maintain temperature, blood glucose levels and are breastfeeding/suck feeding satisfactorily. This is after they have a medical review and they are to be admitted as a qualified baby under the care of a Neonatologist.

Babies who weigh 2000 - 2500 gms will be assessed by a Neonatal Registrar as soon as possible and may require extra monitoring and care to maintain normoglycaemia and the provision of additional feeds to avoid excessive weight loss.

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Section 1 – Admission

The baby is admitted to the postnatal or antenatal ward with the mother.

Admission Procedure The first midwifery ‘Baby Check’ is attended at birth and is recorded on the Neonatal

Early Warning Score (NEWS) chart complete risk assessment as per NEWS chart and schedule observations as per risk on

NEWS chart complete all admission documentation check baby name tags are correct and in place on both of the baby’s ankles with both

the mother and the transferring midwife.

Clinical handover from Birthing to postnatal attended as per the Clinical Handover Procedure: Identification Situation Background Assessment Recommendation

Initiate Baby Feed Chart and keep the Birth Summary with this chart perform and record temperature, apex beat, respirations and oxygen saturation and

document on NEWS observation chart first feed to be documented on baby’s feeding chart document admission entry into the baby's clinical notes complete BOS (Birthing Outcome System) place a copy of the Birth Summary in the Baby Health Record (Blue Book), place the

baby’s name sticker on it and give it to the mother.

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Section 2 – Care of Qualified Babies

A clinically qualified baby will require an admission to the maternity unit. The baby will be admitted under the care of a neonatologist; be reviewed daily by the neonatal registrar have a plan of care and have a Discharge Summary completed on discharge. As per: Attachment 1 Newborn Status Flowchart

Criteria for a clinically qualified baby: Babies requiring nasogastric/orogastric gavage (NG) feeding – two or more times in 24

hours management of babies with hypoglycaemia as per CHHS SOP Hypoglycaemia of the

Newborn jaundice requiring phototherapy treatment as per CHHS SOP Jaundice in the Newborn

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babies receiving IV antibiotic treatment who are otherwise well palliative/comfort care babies readmitted to maternity unit with a medical condition (e.g. weight loss) under 14

days old and not requiring admission to the NICU/SCN and accompanied by the mother as a boarder

baby who remains in hospital with a medical condition and whose mother accompanies the baby as a boarder.

Procedure Care of the clinically qualified baby in the maternity unit – postnatal/antenatal ward The baby requires a medical admission and daily (or as required) review by the neonatal

registrar clinically qualified babies require allocated midwifery/nursing time and resources for

their additional needs/cares. Should the patient numbers, acuity or staffing change the Clinical Midwife Consultant (CMC)/team leader is to refer to the ‘Maternity Escalation Plan’

qualified babies not admitted to the NICU/SCN will require a copy of the ‘Birth Outcome Summary’, Discharge Summary (completed by midwife), as well as a GP Discharge Summary (completed by the neonatal registrar) included in their clinical notes

babies admitted to NICU/SCN should have a discharge summary completed within 24 hours of transfer/discharge to the maternity unit and updated on discharge from maternity

documentation of further care is to be entered into BOS all midwives/nurses caring for qualified babies will be given ongoing relevant education,

training and CDM/N support babies must be discharged by a medical officer (neonatal registrar) and Discharge

Summary completed babies assessment, care and discharge is the responsibility of the midwife and neonatal

doctor.

Note: All babies admitted to the NICU/SCN retain their clinical qualification status for the duration of their hospitalisation.

Criteria for an administratively qualified babyAdministratively qualified babies do not require a review by a neonatal registrar unless there is a clinical indication. As per Attachment 1 Newborn Status Flowchart .

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Administrative qualification includes: The second or subsequent well live born baby of a multiple birth, whose mother is

currently an admitted patient a previously unwell baby transferred from the NICU/SCN to the antenatal or postnatal

ward that does not have an ongoing clinical qualification a baby who has been admitted to a Tertiary Level 3 or SCN in a hospital, being a facility

approved by the Commonwealth Minister for the purpose of the provision of special care, or remains in hospital without its mother

a baby admitted/transferred with an unwell mother a baby admitted after being ‘out born’ (born before arrival; homebirth).

When a baby reaches 10 days of age, the qualification status needs to change from unqualified to qualified. The Charge Class must be changed to one of the following: Medicare Shared Private Shared Private Uninsured Shared Non Eligible or Reciprocal Health Care Agreement.

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Section 3 – Monitoring the baby’s health and well-being

Babies must be kept warm during the early days of life, with skin to skin being most important and effective for thermo-regulation. The Neonatal Early Warning Score (NEWS) chart should be completed as per risk assessment.

If the baby has not attached and sucked well at the breast within the first two-three hours of life, encourage the mother to express and give available Expressed Breastmilk (EBM) via a syringe. For more information please see CHHS Breastfeeding – Ten Steps to Successful Breastfeeding guideline.

Encourage the mother to continue hand expressing 3 hourly for the next 24 – 48 hrs and offer EBM to baby after breastfeeds.

Procedure: as per Attachment 3: Guide to Feeds and Output of Babies

Day 1 (First 24 hours) Check the baby has attached and breastfed well after birth after the first breastfeed, the baby may enter a long sleep period or may be wakeful and

feed frequently, 2 or more breastfeeds in the first 24 hours is acceptable in normal term, healthy newborns, with no identified risk factors

observe skin colour, acrocyanosis is normal, any evidence of jaundice needs to be investigated

attend observations at birth according to the risk factors identified on the NEWS chart or on admission to the wards. Observations to be attended 12 hourly, if no risk factors are identified

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babies may be ‘mucousy’ after birth, this is swallowed amniotic fluid and some swallowed birth fluids, this is normal.

Output Observe for urine output: urine may be passed once or more in the first 24 hours Stools: One or more meconium stool.

Day 2 (24 –48 hours) The baby has 6 – 8 or more breastfeeds in the 24 - 48 hour period demonstrating active

feeding behaviours. Observe skin colour, any evidence of jaundice needs to be investigated

observations as per NEWS chart.

Output Urine: 2 or more wet nappies – urates may be seen, this is normal. Stools: 2 or more meconium – transitional stools.

Day 3 (48 – 72 hours) Check the baby has active feeding behaviour with 6 – 8 or more effective breastfeeds.

suck/swallow should be audible during feeds.

Output Urine: 3 or more wet nappies – urates may be seen, this is normal. Stools: 3 or more transitional – yellow stools.

Day 4 (>72 hours) Baby will be effectively breastfeeding 8 – 16 times per day with an audible suck/swallow babies should have at least 6 – 8 breastfeeds.

Output Urine: 4 – 6 or more wet nappies – the presence of urates may indicate a delay in

lactation and should be investigated. Stools: several stools daily, yellow/mustard stools with little curds.

Cluster feedingBabies will cluster feed to increase their mother’s breastmilk supply, this is normal and women should be encouraged to switch feed during this stimulation phase. Women should be educated that this is normal and may continue at anytime throughout lactation.

Feeding CuesCrying is a late sign for hunger and needs to be investigated if persistent.Babies go through a sequence of feeding cues to alert their mothers that they are hungry, rooming in and demand feeding enhances their mother’s ability to recognise these cues.

Sleepy babies

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Babies who did not breastfeed within an hour after birth and do not appear interested in breastfeeding require a neonatology review. Full assessment of the baby needs to be undertaken. Babies who breastfed well at birth and then are too sleepy to breastfeed again require EBM supplementation via a syringe or cup.

Bare WeightBaby should be weighed on Day 3 (at around 72 hours of life).

Newborn assessment Babies should have a formal newborn assessment prior to discharge from the maternity unit. If this occurs before 72 hrs of age, a repeat cardiovascular check by the GP or credentialed midwife is recommended at 7 – 10 days of age.

Evaluation of babyThe midwife is responsible to attend observations on the baby as per NEWS observation chart and monitor feeds and urine output each shift.

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Section 4 – Care of the Small Baby

Babies <2kg will be cared for in SCN babies >2kg will be admitted to the postnatal ward and assessed by the neonatal

registrar babies < 2kg may be transferred to the postnatal ward from NICU/SCN when they are

able to maintain temperature, blood glucose levels and are breastfeeding/suck feeding satisfactorilyo Small for Gestational Age (SGA) babies will have 4 hourly observations for the first

48 hours and then 6 – 8 hourly observations until discharge as per the CHHS Vital Signs & Early Warning Scores Clinical Procedure

Monitoring of the baby is important as they are susceptible to the following conditions: o hypothermiao jaundiceo hypoglycaemiao feeding difficulties.

Hypothermia Maintain temperature between 36.5 – 37.50C encourage skin to skin to assist with temperature stability monitor the temperature per axilla 4th hourly apply bootees and extra wraps to help maintain temperature if temperature is difficult to maintain a warming blanket (kept in SCN) can be used.

Feeding and Hypoglycaemia

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Initiate early breast feeding to stabilise blood glucose levels (within 30 – 60 minutes of birth)

ensure good oral intake and consider gavage tube top-up where necessary or until infant effectively transfers milk

refer to Attachment 3 for input/output assessment/management offer breast feeds whenever the baby cues to feed (frequent feeding may cause baby to

become tired and result in poor milk transfer) monitor for signs of intolerance (increased vomiting) instruct mother to express breast milk if transfer is not adequate consider supplemental feeds where necessary (breast fed babies usually take less breast

milk, but if they feed well and do not become hypoglycaemic, no complimentary feeds are necessary)

follow the CHHS Hypoglycaemia of the Newborn SOP and flow chart for management guidelines

If the mother chooses to bottle feed, offer a bottle whenever the baby cues; or offer a minimum of 8 feeds per 24 hours.

Jaundice SGA babies are at increased risk for jaundice follow the CHHS Jaundice in the Newborn procedure for management guide commence a jaundice chart and monitor Serum Bilirubin (SBR) results, if <37 weeks

gestation use the preterm chart if a baby shows signs of deterioration as per the NEWS chart, consult the neonatal

registrar as per the NEWS flowchart.

Discharge Criteria: as per Attachment 2: Discharge Summary Responsibility for qualified babies Temperature stability blood glucose levels within normal limits regular suck feeding with signs of milk transfer minimal weight loss – weight to be done at 72 hours of age and repeated every 3 days

(<10% of birth weight with subsequent weight gain) refer to Appendix A post discharge follow-up by MIDCALL/Canberra Midwifery Program (CMP) or Continuity

at the Canberra Hospital (CatCH) or if ineligible a priority Maternal and Child Health (MACH) referral should occur within 2 days

follow-up for growth and development should be arranged with a medical officer, either paediatric outpatient services or GP

documentation will include a neonatal discharge summary, completed BOS, Community discharge summary and a completed Personal Health Record (Blue Book).

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Section 5 – Weighing of Babies

A baby may lose up to 5 - 10% of birth weight in the first week and should regain this by 2 – 3 weeks.

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Weight loss of >10% in the first 3 days may lead to dehydration and may be associated with significant physiologic disturbances, such as hypernatraemia, hypoglycaemia and jaundice.

Equipment Baby scales

Procedure Birth weight to be witnessed by family member or another staff member and the

woman’s partner all babies will be weighed on day 3 postnatal (as close to 72 hours post birth as possible) all women will be educated regarding prenatal expression and encouraged to express

from 36 weeks gestation. Women will be asked to bring the collected EBM to hospital with them on admission should the baby need additional feeding.

Determine appropriate course of action according to the chart below

Weight loss < 7% Weight loss >7% and <10% Weight loss > 10% Continue with current

feeding plan, re-weigh baby on day 6 or on discharge from service

Reassure woman the feeding is going well and to continue demand feeding

Offer more frequent breastfeeds (3 – 4 hourly)

Observe feeding, noting latch, sucking/swallowing and breast softening

Express after feeds and top-up baby with EBM

Re – weigh baby daily Record number of wet

nappies If 2 or less wet nappies in

24 hours after day 1 inform neonatal registrar

Review feeding plan Baby can be managed by

Midcall, Canberra Midwifery Program (CMP) and Continuity at the Canberra Hospital (CatCH)

As per previous plan Neonatal consult (baby

may require top-ups, a blood test or admission for IV rehydration)

Breastfeeding assessment including, observation of feed, review of output and newborn behaviour. Maternal history.

Weigh daily until adequate weight gains

Practice Note:The following calculation can be used to determine the percentage of weight loss:Percentage of weight loss: weight loss ÷ birth weight × 100 E.g. Weight loss: 300 gmsBirth weight: 3600 gms

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Percentage of weight loss: 300 gms ÷ 3600 gms × 100 = 8.3%

Note: If there is considerable discrepancy in weight difference please check that scales are working correctly and that the birth weight has been accurately recorded. Test weights are available on the postnatal ward.

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Implementation

This Clinical Procedure will be referred to in existing delivery of education. Will be discussed at inservice and maternity multidisciplinary education, emailed to staff and placed on ward desks.

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Related Policies, Procedures, Guidelines and Legislation

PoliciesPatient Identification and Procedure Matching Policy. Nursing and Midwifery Continuing Competence Policy.Scope of Practice for Nurses and Midwives Policy.

Clinical GuidelineBreastfeeding – Ten Steps to Successful Breastfeeding.

Procedures Clinical Handover ProcedurePatient Identification and Procedure Matching Procedure Patient Identification – Pathology Specimen Labelling SOPHealthcare Associated Infections procedureHypoglycaemia in the Newborn SOPJaundice in the Newborn SOP

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References

Das UG, Sysyn GD. (2004). Abnormal fetal growth: intrauterine growth retardation, small for gestational age, large for gestational age. Pediatr Clin North Am. 2004; 51(3):639-54, viii.

Fransson AL, Karlsson H, Nilsson K. (2005) Temperature variation in newborn babies: importance of physical contact with the mother. Arch Dis Child Fetal Neonatal Ed; 90(6):F500-4.

Forster DA, McLachlan HL. (2007) Breastfeeding initiation and birth setting practices: a review of the literature. J Midwifery Womens Health. 52(3):273-80.

Lawrence E. (2006) Part 1: A matter of size: Evaluating the growth-restricted baby. Advances in Neonatal Care; 6(6):313-322.

Levene M, Tudehope D, Sinha S. (2008) Thermoregulation. In: Essential Neonatal Medicine. Australia: Blackwell Publishing.

Mandruzzato G. (2008). Intrauterine growth restriction (IUGR): Guidelines for definition, recognition and management. Arch of Perinatal Medicine [Editorial]. 2008; 14(4):7-8.

Matthews, A and Robin, N. (2006) “Genetic disorders, malformations, and inborn errors of metabolism.” In Merenstein G and Gardner, S Ed Handbook of Neonatal Intensive Care 6th Ed. Mosby Inc St Louis.

Moore ER, Anderson GC, Bergman N. (2007) Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2007; (3):CD003519.

NSW Policy Directive 24 march (2005). Newborn Screening Guideline.

National Institute for Health and Care Excellence (NICE) (2006) Postnatal Care. Downloaded http://guidance.nice.org.uk/CG37/NiceGuidance/pdf/English

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Definition of Terms

Acrocyanosis: a normal transient condition of the newborn characterized by pale cyanotic discoloration of the hands and feet, especially the fingers and toes.

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Search Terms

Baby, Postnatal Ward, Antenatal Ward, Admission Criteria, Qualified Babies, Small Baby,Weight, Newborn Screening Test.

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Attachments

Attachment 1: Newborn Status FlowchartAttachment 2: Discharge Summary Responsibility for Qualified BabiesAttachment 3: Guide to Feeds and Output of Babies

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment 1: Newborn Status Flowchart

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NEWBORN QUALIFIEDAdministrative / Bedside

QUALIFIEDClinical

StatisticalDischarge

Criteria Admitted at Birth

Single birth or first live baby of multi-birth

≤ 9 Days of age

Criteria 1Multi-Birth

≥ 10 days old Newborn re-admitted with unwell

Mother Newborn & Mother admitted following non-hospital birth

(Planned)

D/C WardNICU

orNICU to NAQ/ANQ

Document

Notification of Care Type Change

DocumentDifferent name now

DocumentMaternity Discharge Summary

(BOS)

DocumentCentre for Newborn Care

ProfessionalDoctor

ProfessionalMidwife

ProfessionalMidwife

D/C WardNAQ/ANQ

Criteria 24. Newborn transferred from

another hospital with unwell Mother

5. Newborn & Mother admitted following non-hospital birth

(Un-Planned)

DocumentNeonatal Assessment – GP

Discharge Letter

DocumentElectronic D/C Summary

(Concerto)

ProfessionalObstetric Doctor

CHHS16/052

Attachment 2: Discharge Summary Responsibility for Qualified Babies

tachment 2: Discharge Summary Responsibility for qualified babies

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Attachment 3: Guide to feeds and output of babies

Age Volume of breast milk/day

Feeds/day

Volume of formula for bottle fed babies

Urine/day Number of stools

Stool colour

Stool consistency

Baby weight

Day 1

0-5ml colostrum at first feed7-123 ml of colostrum/day

5-8 60mls/kg/day 1 concentrated may contain urates

1 Black Tarry/sticky

Day 2

Increasing volumes

5-10 80mls/kg/day 2-3 concentrated may contain urates

1-2 Greenish/black

Softening

Day 3

Increasing volumes

5-10 100mls/kg/day 3-4 paler, but may be concentrated may contain urates

3-4 Greenish/yellow

Soft Less than 10% loss

Day 4

395-800 mls 5-10 120mls/kg/day 4 -6 pale no urates

4 large or 10 small

Yellow/seedy

Soft/liquid Between day 4-6 begins to gain weight

Day 5

Increasing volumes

8-12 140-150mls/kg/day

>6 pale urine 4 large or 10 small

Yellow/seedy

Soft/liquid

Weight gain or loss is only one aspect of baby wellbeing to consider

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