Care of the well Baby



Canberra Hospital and Health ServicesClinical ProcedureCare of the Well Baby (Excluding Neonatal Intensive Care Unit and Special Care Nursery)Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc449426788 \h 1Purpose PAGEREF _Toc449426789 \h 2Scope PAGEREF _Toc449426790 \h 2Alerts PAGEREF _Toc449426791 \h 2Section 1 – Admission PAGEREF _Toc449426792 \h 3Section 2 – Care of Qualified Babies PAGEREF _Toc449426793 \h 3Section 3 – Monitoring the baby’s health and well-being PAGEREF _Toc449426794 \h 5Procedure: as per Attachment 3: Guide to Feeds and Output of Babies PAGEREF _Toc449426795 \h 5Section 4 – Care of the Small Baby PAGEREF _Toc449426796 \h 7Section 5 – Weighing of Babies PAGEREF _Toc449426797 \h 9Implementation PAGEREF _Toc449426798 \h 10Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc449426799 \h 10References PAGEREF _Toc449426800 \h 11Definition of Terms PAGEREF _Toc449426801 \h 11Search Terms PAGEREF _Toc449426802 \h 12Attachments PAGEREF _Toc449426803 \h 12Attachment 1: Newborn Status Flowchart PAGEREF _Toc449426804 \h 13Attachment 2: Discharge Summary Responsibility for Qualified Babies PAGEREF _Toc449426805 \h 14Attachment 3: Guide to feeds and output of babies PAGEREF _Toc449426806 \h 15PurposeTo 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]).ScopeThis document applies to:Medical OfficersMidwives 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.ScopeAlertsIf 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 breastfeedingdecreased urinary output as per number of days since birthdecreased stools or persistent meconium 3 days post birthexcessive feeding cuessleepiness, ora 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.Section 1 – AdmissionThe 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) chartcomplete risk assessment as per NEWS chart and schedule observations as per risk on NEWS chartcomplete all admission documentationcheck 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:IdentificationSituationBackgroundAssessmentRecommendationInitiate Baby Feed Chart and keep the Birth Summary with this chartperform and record temperature, apex beat, respirations and oxygen saturation and document on NEWS observation chartfirst feed to be documented on baby’s feeding chartdocument admission entry into the baby's clinical notescomplete 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.Back to Table of Contents Section 2 – Care of Qualified BabiesA 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 hoursmanagement 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 wellpalliative/comfort carebabies 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 boarderbaby 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 wardThe baby requires a medical admission and daily (or as required) review by the neonatal registrarclinically 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 notesbabies 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 maternitydocumentation of further care is to be entered into BOSall midwives/nurses caring for qualified babies will be given ongoing relevant education, training and CDM/N supportbabies must be discharged by a medical officer (neonatal registrar) and Discharge Summary completedbabies 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. Administrative qualification includes:The second or subsequent well live born baby of a multiple birth, whose mother is currently an admitted patienta previously unwell baby transferred from the NICU/SCN to the antenatal or postnatal ward that does not have an ongoing clinical qualificationa 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 mothera baby admitted/transferred with an unwell mothera 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 SharedPrivate SharedPrivate Uninsured SharedNon Eligible or Reciprocal Health Care Agreement.Back to Table of ContentsSection 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 BabiesDay 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 factorsobserve 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 identifiedbabies may be ‘mucousy’ after birth, this is swallowed amniotic fluid and some swallowed birth fluids, this is normal.OutputObserve for urine output: urine may be passed once or more in the first 24 hoursStools: 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 investigatedobservations as per NEWS chart.OutputUrine: 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.OutputUrine: 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/swallowbabies should have at least 6 – 8 breastfeeds. OutputUrine: 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 babiesBabies 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.Back to Table of ContentsSection 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 registrarbabies < 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 satisfactorilySmall 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 ProcedureMonitoring of the baby is important as they are susceptible to the following conditions: hypothermiajaundicehypoglycaemiafeeding difficulties.HypothermiaMaintain temperature between 36.5 – 37.50Cencourage skin to skin to assist with temperature stabilitymonitor the temperature per axilla 4th hourlyapply bootees and extra wraps to help maintain temperatureif temperature is difficult to maintain a warming blanket (kept in SCN) can be used.Feeding and HypoglycaemiaInitiate 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 milkrefer to Attachment 3 for input/output assessment/managementoffer 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 adequateconsider 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 guidelinesIf the mother chooses to bottle feed, offer a bottle whenever the baby cues; or offer a minimum of 8 feeds per 24 hours.JaundiceSGA babies are at increased risk for jaundicefollow the CHHS Jaundice in the Newborn procedure for management guidecommence a jaundice chart and monitor Serum Bilirubin (SBR) results, if <37 weeks gestation use the preterm chartif 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 babiesTemperature stabilityblood glucose levels within normal limitsregular suck feeding with signs of milk transferminimal 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 Apost 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 daysfollow-up for growth and development should be arranged with a medical officer, either paediatric outpatient services or GPdocumentation will include a neonatal discharge summary, completed BOS, Community discharge summary and a completed Personal Health Record (Blue Book).Back to Table of ContentsSection 5 – Weighing of BabiesA 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 scalesProcedure Birth weight to be witnessed by family member or another staff member and the woman’s partnerall 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 serviceReassure woman the feeding is going well and to continue demand feedingOffer more frequent breastfeeds (3 – 4 hourly)Observe feeding, noting latch, sucking/swallowing and breast softeningExpress after feeds and top-up baby with EBMRe – weigh baby dailyRecord number of wet nappiesIf 2 or less wet nappies in 24 hours after day 1 inform neonatal registrarReview feeding planBaby can be managed by Midcall, Canberra Midwifery Program (CMP) and Continuity at the Canberra Hospital (CatCH)As per previous planNeonatal 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 gainsPractice 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 gmsPercentage 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.Back to Table of ContentsImplementation 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.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesPatient 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 SOPBack to Table of ContentsReferencesDas 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 to Table of ContentsDefinition 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.Back to Table of ContentsSearch Terms Baby, Postnatal Ward, Antenatal Ward, Admission Criteria, Qualified Babies, Small Baby,Weight, Newborn Screening Test.Back to Table of ContentsAttachmentsAttachment 1: Newborn Status FlowchartAttachment 2: Discharge Summary Responsibility for Qualified BabiesAttachment 3: Guide to Feeds and Output of BabiesDisclaimer: 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 AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC ChairAttachment 1: Newborn Status FlowchartAttachment 2: Discharge Summary Responsibility for Qualified Babiestachment 2: Discharge Summary Responsibility for qualified babiesNEWBORNQUALIFIEDAdministrative / BedsideQUALIFIEDClinicalStatisticalDischargeCriteria Admitted at Birth Single birth or first live baby of multi-birth ≤ 9 Days of ageCriteria 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/ANQDocumentNotification of Care Type ChangeDocumentDifferent name nowDocumentMaternity Discharge Summary (BOS)DocumentCentre for Newborn CareProfessionalDoctorProfessionalMidwifeProfessionalMidwifeD/C WardNAQ/ANQCriteria 24. Newborn transferred from another hospital with unwell Mother5. Newborn & Mother admitted following non-hospital birth(Un-Planned)DocumentNeonatal Assessment – GP Discharge LetterDocumentElectronic D/C Summary(Concerto) ProfessionalObstetric DoctorAttachment 3: Guide to feeds and output of babiesAgeVolume of breast milk/dayFeeds/dayVolume of formula for bottle fed babiesUrine/dayNumber of stoolsStool colourStool consistencyBaby weightDay 10-5ml colostrum at first feed 7-123 ml of colostrum/day5-860mls/kg/day1 concentrated may contain urates1BlackTarry/stickyDay 2 Increasing volumes5-1080mls/kg/day2-3 concentrated may contain urates1-2Greenish/blackSofteningDay 3Increasing volumes5-10100mls/kg/day3-4 paler, but may be concentrated may contain urates3-4Greenish/yellowSoftLess than 10% lossDay 4395-800 mls5-10120mls/kg/day4 -6 pale no urates4 large or 10 smallYellow/seedySoft/liquidBetween day 4-6 begins to gain weightDay 5 Increasing volumes8-12140-150mls/kg/day>6 pale urine4 large or 10 smallYellow/seedySoft/liquidWeight gain or loss is only one aspect of baby wellbeing to consider ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download