/ CHHS16/052

Canberra Hospital and Health Services

ClinicalProcedure

Care of the Well Baby (Excluding Neonatal Intensive Care Unit and Special Care Nursery)

Contents

Contents

Purpose

Scope

Alerts

Section 1 – Admission

Section 2 – Care of Qualified Babies

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

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

Section 4 – Care of the Small Baby

Section 5 – Weighing of Babies

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Attachments

Attachment 1: Newborn Status Flowchart

Attachment 2: Discharge Summary Responsibility for Qualified Babies

Attachment 3: Guide to feeds and output of babies

Purpose

To provide a guide for the admission and care of babiesto 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 ababy 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 3days post birth
  • excessive feeding cues
  • sleepiness, or
  • ajaundiced appearance.

Babies who weigh less than 2000gms, 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 2000gmsor 36 weekswhen 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 beadmitted as a qualified baby under the care of a Neonatologist.

Babies who weigh 2000-2500 gmswill 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.

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 theBirthSummary 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
  • documentadmission 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 babywill require an admission to the maternity unit. The baby will be admitted under the care of a neonatologist; be reviewed daily by the neonatal registrarhave 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/orogastricgavage (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
  • 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 clinicalnotes
  • 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 baby

Administratively qualified babies do not require a review by a neonatal registrar unless there is a clinical indication. As per Attachment 1 Newborn Status Flowchart.

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 availableExpressed 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
  • 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 audibleduring 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 feeding

Babies 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 Cues

Crying 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

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 Weight

Baby 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 72hrs of age, a repeat cardiovascular check by the GPor credentialed midwife is recommended at 7 – 10 days of age.

Evaluation of baby

The 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 assessedby 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 satisfactorily
  • 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:
  • hypothermia
  • jaundice
  • hypoglycaemia
  • 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

  • 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 CHHSHypoglycaemia of the Newborn SOP and flow chart for management guidelines
  • If the mother chooses to bottle feed, offera 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 theCHHS Jaundicein the Newbornprocedure 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 perAttachment 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 apriority Maternal and Child Health (MACH) referralshould 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.

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 determinethe percentage of weight loss:

Percentage of weight loss: weight loss ÷ birth weight × 100

E.g. Weight loss: 300 gms

Birth weight: 3600gms

Percentage of weight loss: 300gms ÷ 3600gms × 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

Policies

Patient Identification and Procedure Matching Policy.

Nursing and Midwifery Continuing Competence Policy.

Scope of Practice for Nurses and Midwives Policy.

Clinical Guideline

Breastfeeding – Ten Steps to Successful Breastfeeding.

Procedures

Clinical Handover Procedure

Patient Identification and Procedure Matching Procedure

Patient Identification – Pathology Specimen Labelling SOP

Healthcare Associated Infections procedure

Hypoglycaemia in the Newborn SOP

Jaundice 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.