The Postnatal Ward Handbook:



Ashford and St. Peter’s Hospitals NHS Foundation Trust

Neonatal Intensive Care Unit

The Postnatal Ward Handbook:

Duties and responsibilities of the junior doctors

The Routine examination of the newborn

Commonly encountered problems:

1. Cardiovascular system

2. Respiratory system

3. Neurological system

4. Gastrointestinal system

5. Musculoskeletal system / Orthopaedics

6. Renal system

7. Genitalia

8. Eyes

9. Infections / BCG and other vaccinations

10. Feeding / Palate

11. Physiotherapy F/U

12. Audiology

13. Syndromes

14. Others

Please note:

The clinical guideline links in this handbook are correct as at the publication date. If a link is broken, this document will need to be updated accordingly.

The full list of neonatal guidelines can be found on the trust intranet.

Duties and responsibilities of the junior doctors

There are 3 postnatal ward SHOs – one for Special Care Unit and two for Joan Booker Ward and you will all work together as a team.

The GP trainees and the FY2s from General Paediatrics are mainly allocated to do the baby checks (“Baby check SHO”).

The NICU SHOs are mainly responsible for seeing any babies that need a paediatric review (“Neonatal Reviews SHO”). The NICU SHO will help and support the “Baby Check SHO”, once all babies that require bloods or a management plan are seen.

This role allocation does not mean that there is no cross-over of responsibilities. The GP trainees and FY2s should not refuse to review any babies if asked by the midwifery team. Equally, the NICU SHOs should not leave all the baby checks to their General Paediatric colleagues.

The aim is for all babies to be seen in the morning and have a baby check.

You should start with the babies that are likely to be discharged home the same day, but all babies on JBW should receive a baby check allowing the MWs to discharge the babies and mothers as soon as possible.

Please don’t leave any checks for out of hours or the next day.

You will be asked to read about the routine examination of the newborn and be able to differentiate between normal variants and abnormalities that require intervention. You will have an induction on baby checks and a senior SHO or a Registrar will supervise you on your first working day (you will be observed for 10 baby checks or less if you feel confident or had previous experience). You are required at the end of the day to sign an educational agreement and you will be formally assessed with a CEX on the routine examination of the newborn.

Aim to perform 3-4 checks per hour and time yourself to know your pace and be able to identify early if you need extra help. This may be difficult in the beginning and the NICU SHOs and SpRs will help you, until you acquire the skills to perform the newborn examination, learn the different management protocols and be able to manage your workload.

Bleeps

|5240 |“Baby Check” SHO bleep – GP trainees and FY2s form the Paediatric department |

|5495 |“Neonatal Reviews” SHO bleep – NICU SHOs |

|5496 |“SCU” SHO bleep – NICU SHOs |

|5960 |PN Ward SpR |

The “Baby Check” SHO bleep must be handed over in the morning by the night NICU SHO. The “Baby check SHO” should be informed of any babies that warrant an urgent review.

At the end of the shift the “baby check SHO” should come up on the unit and hand over the bleep and any problems to the long day SHO.

The rest of the bleeps will be kept in the doctor’s office on NICU out of hours.

The timetable for the “baby check SHOs” is:

Monday: 08:30 – 16:30

Tuesday: 08:00 – 16:00

Wednesday: 09:00 – 17:00

Thursday: 08:00 – 16:00

Friday: 08:00 – 16:00

Saturday: 08:00 – 11:00

Sunday: 08:00 – 11:00

The timetable for the “SCU SHOs” is:

Monday: 09:00 – 16:00

Tuesday: 09:00 – 16:00

Wednesday: 09:00 – 16:00

Thursday: 09:00 – 16:00

Friday: 09:00 – 16:00

Saturday: 09:00 – 18:00

Sunday: 09:00 – 18:00

The PN ward SpR is expected to attend the PN ward around midday. He/She will review the babies on SCU and any babies on JBW that the SHOs have identified with abnormalities or have any questions about their examination. If this does not happen the SHOs should take the initiative and contact the SpR on their bleep. SHOs should not feel intimidated and are always welcome to discuss their queries with the SpRs or the attending Consultants. The Neonatal Unit is almost always busy but time will be made to review babies on the postnatal ward.

The baby checks should be performed in the Nursery. All the equipment should be made available to you and a Nursery Nurse or a Health Care Assistant should be helping you, by gathering the babies and mothers next door with their notes.

When both the “Baby check SHO” and the “Neonatal reviews SHO” are available for baby checks, the checks should still be performed in the nursery, but at no point should two families be in the same room discussing potentially sensitive data. Please try to co-ordinate between you, so that while one is taking a family history and examines a baby, the other person is filling in paperwork, prepares for blood tests or BCGs, in order to improve efficiency.

Remember to check when you start in the morning whether any of the babies on your list have been antenatally identified as “High Risk” and are logged on the “High Risk Folder” (the yellow folder).

▪ A management plan (e.g. for talipes, antenatal hydronephrosis, Hepatitis B) is noted next to the baby’s name and problem list to help you arrange investigations and follow up.

▪ Please tick the baby’s name off and document the management you have carried out on the same page. This can be fed back to the Obstetric team at the mother and baby meeting on alternate Fridays during the NICU grand round.

▪ If you have any concerns or queries, please discuss them with the SpR or attending Consultant.

A set of notes needs to be made up for all the babies that require anything more than a routine baby check (ie investigations, senior review, follow up). You are expected to write your examination and management plan in them so that this can be followed up if required.

***Do not write in the postnatal baby notes (blue set of notes) as the mothers take these notes home and are filled later on with the maternal notes.***

Follow up in Paediatric Outpatient Clinic

▪ The follow up appointment is booked via the secretaries in the Paediatric Outpatient Department. Please ask the JBW clerk to call 2509 or 2545 to arrange the appointment and let the secretaries know the name of the attending Consultant on NICU in order to book the appointment. If there isn't a ward clerk available a nurse or MW will need to arrange this.

Family History

The family history relevant to the routine examination of the newborn is poorly and inconsistently obtained.

Thus, you are now asked to fill in the Red Book the section regarding the family history, on page 6.

It consists of 9 questions that are answered with a yes and no format. These include:

▪ Childhood deafness; depending on the history (ie first degree relative with sensorineural deafness) you may need to discuss with a Registrar or a Consultant and arrange follow up in clinic. The HV will be performing a hearing screen on all babies in the community.

▪ Fits in childhood; The risk for unprovoked seizures is higher in children of parents who developed epilepsy before 20 years of age (nine per cent). Please advise to look out for seizures.

▪ Eye problems;

o Congenital cataracts and

o Retinoblastoma

are the main concerns and require follow up (see guideline below).

▪ Hip problems; increased likelihood of DDH on first degree relatives (see guideline below).

Remember to ask whether the baby was in breech position at any point in the 3rd trimester.

▪ Reading and spelling difficulties;

▪ Asthma, eczema, hay fever, allergies; increased likelihood for first degree relatives

▪ Tuberculosis; offer the BCG vaccine

▪ Heart Conditions; the incidence of congenital heart disease is around 1% and there is increased likelihood of congenital heart disease in first degree relatives. Check that the antenatal scans were normal and check whether an antenatal ECHO was performed. Look at the high risk folder in case an antenatal plan was formed. Perform a thorough cardiovascular examination and check oxygen saturations.

▪ Any other particular illnesses or conditions in the mother’s or father’s family that you feel are important?

BCGs

The BCGs should all be performed in the morning and you can open the vial and use it for 4hrs (once reconstituted and kept in room temperature). The babies requiring a BCG should be identified antenatally and there is a section in the maternal notes indicating whether the baby needs a BCG. Please consent the parents before you perform the baby check and administer the vaccination while the baby is undressed at the end of your examination.

Try to open one vial per day if possible and vaccinate as many babies as possible. If there are any extra babies for BCG vaccination in the afternoon or out of hours, then it is preferable to open another vial rather than bringing the baby back in just for the vaccination.

You will be expected to observe how a BCG is given for a couple of times before you attempt to give one. A Senior SHO or a Registrar will supervise you for the first few injections until you feel confident with the procedure. This should be arranged on the same day that you are supervised for your baby check training. A DOPS form will be filled in to ensure you are competent.

For the BCG guideline please click here.

Special Care Unit

The SCU is managed by a NICU SHO; and the SpR allocated to the PN ward should help and supervise you as required.

It is helpful to have the SCU nurse with you on the ward round, so you both know the plans for the babies.

There are strict criteria for SCU eligibility – if you wish to admit a baby to SCU please speak to the nurse in charge.

If a baby is to be discharged ensure they have:

← A completed formal baby check (documented in Red Book and Evolution Page)

← Information on the BCG vaccine and been offered it (duty of SCU SHO to consent and administer SCU babies BCG vaccine)

← A completed SEND discharge summary

← Any necessary follow-up

← You are also responsible for completing the SEND daily updates for the babies in SCU.

SCU Ward Attendees

Babies who have gone home and are coming back to the SCU for review or investigations (e.g. TFT’s, prolonged jaundice screens, FBC) are booked in the SCU diary.

The appointments are on Monday, Tuesday, Thursday and Friday at 14:00 & 14:30 (2 appointments available per day). These are to be used once or maximum twice for the same patient. If further follow up is required, this needs to be arranged through the Outpatient Department, with their Named Consultant (ie the Neonatal Consultant attending NICU on the day the baby was born).

Their results should be reviewed daily and the appropriate action taken. This includes calling the parents to inform them of normal results or making appointments for review or further tests.

The routine examination of the newborn

Equipment: stethoscope, ophthalmoscope, tape measure +/- Sats probe

Wash hands thoroughly (don’t use alcohol gel as when you check for the sucking reflex it is bitter for the baby). Wear gloves if you prefer (you‘ll need to handle the nappy area even if the baby has had their bowels open!).

Initial Details

Thoroughly review the maternal notes, regarding:

▪ antenatal scans (e.g. hydronephrosis – see guideline)

▪ blood tests (e.g. Hep B / HIV – see guideline)

▪ full history –past medical (e.g. maternal hyperthyroidism – f/u bloods required) and obstetric history

▪ pregnancy complications

▪ details of labour and delivery (ROM, type of delivery, meconium, GBS carrier, Apgars, weight)

▪ gestational age and sex of the baby

There may be plans in place for postnatal investigations and management –

remember to check the (yellow) high risk folder.

Getting started

▪ Introduce yourself

▪ Ask mother if she has any concerns about the baby.

▪ Any problems in the pregnancy

▪ Any relevant family history (e.g. hips, heart, eyes, hearing and kidneys). Fill in page 6 on the RED BOOK.

▪ Enquire about the infant’s progress since birth, method of feeding, adequacy of intake, alertness.

▪ Has the baby been on meconium or PROM (prolonged rupture of membrane) observations - any abnormal temperature or other observations?

▪ Has the baby had blood sugar monitoring due to hypoglycaemia risk – see guideline

▪ Has the baby passed urine (most within 24hrs) and in boys is there a good stream?

▪ Has the baby passed meconium (90-95% by 48 hrs)?

▪ Was Vitamin K given i.m. or oral – With oral regime TTO for follow up doses required – see guideline

Initial Observations - Is the infant well?

Perform a general observation of the baby, including:

Colour :

▪ Cyanosis, pallor, jaundice – check a spun bilirubin level if concerned

▪ Blueness of hands and feet are common (acrocyanosis)

▪ Blueness of face ± facial petechiae common from cord around the neck / rapid second stage (facial contusion)

▪ Tip: examine the tongue – it should be pink. If any doubt about possible cyanosis, check oxygen saturations.

Respiratory pattern and rate – should be regular and 95% and the baby is asymptomatic:

1. re-examine in 24 hours’ time, ideally by the same person.

2. If murmur still present, examination by a senior colleague to confirm that the murmur is clinically insignificant.

3. If so, arrange an appointment in 4 to 8 weeks’ time, provide a parent information sheet on heart murmurs & advise to return to hospital if there is:

← Central cyanosis

← Respiratory distress and/or excessive sweating

← Poor feeding (>2 consecutive feeds of ................
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