The following are some guidelines and list of conditions which may be managed by obstetric house staff and Lead Maternity Carers on postnatal wards.

Please note that all referrals are to be directed to the Paediatric Registrar or Paediatric House Surgeon who with Dr Aftimos is on for the postnatal wards. All signatures must be clear, printed if necessary so that we can audit problems when they occur.

Tachypnoea

• The normal respiratory rate is between 40-50/minutes.
• Some normal healthy infants will breathe at 50-60.
• If the respiratory rate is consistently above 60/minute, babies should be referred to the Paediatric Registrar.

Meconium Exposure

• Where the Paediatric house staff have attended the delivery and there are no problems, care should be handed over to the obstetric staff.
• Most of these babies will present within the first 6 hours. AC temperature and respiratory recordings should be for 24 hours on the postnatal ward. If respiratory rates >60/minute and/or temperature >37.5°C, the infant should be examined and then referred to the Paediatric Registrar.

NB If the infant is feeding well and pink on examination, and seems normal despite the presence of a fever or tachypnoea, then a chest x-ray and full blood count could be organised before being seen by the Paediatric Registrar.

Infants of Diabetic Mothers

• These babies are at risk of hypoglycaemia.
• Blood glucose measurement should be requested for one hour and 4 hourly for 12 hours.
• Feeding should be 3 hourly.
• If blood glucose (preferably pre-feed) is <2.6mmol/L repeat feed (either complement NIF or BF) should be given and the glucose repeated in one hour. If the repeat is <2.6mmol/L refer to the Paediatric Registrar.
• If a blood glucose is <2.2mmol/L, immediate referral is necessary.
• The volume of complement feed will vary according to size of infant - usually 15-30ml.

See the guideline for management of infants of diabetic mothers on the postnatal ward.

Low Birthweight (<2.5kg) and Intrauterine Growth Retardation

• If birthweight 2.2-2.5kg refer to the Paediatric Registrar at delivery. They may elect to leave the baby under obstetric care with instructions as for intrauterine growth retardation.
• If birthweight is <10% for gestation or if infant looks especially thin and malnourished (this is a subjective assessment), one hourly blood glucose and 4 hourly for 24 hours, 3 hourly feeds (complements will probably be necessary and may be ordered from the outset).
• If the blood glucose is <2.6mmol/L, the baby should be fed complement NIF and blood glucose repeated in one hour. If the repeat blood glucose is <2.6mmol/L refer back to Paediatric Registrar.
• If a blood glucose is <2.2mmol/L immediate referral is necessary.

See guideline on hypoglycaemia

Prematurity

• These infants must be referred to the Paediatric Registrar who may decide (especially >36 weeks) to leave them under obstetric care. Where there is doubt about gestation, refer to registrar for their opinion.

Temperature Control

• Hypothermia is a major problem with low birthweight and growth retarded infants. These infants should be wrapped well and kept in a warm room with no drafts.
• Temperature of <36.5°C are abnormal and re-warming efforts should be carried out.
• If the temperature is below 36.2°C in the first 24 hours, the baby should be placed in an incubator in the ward nursery, and if not up above 36.8°C in 4 hours, refer to the Paediatric Registrar.
• Temperature instability after the first day should be referred to the Paediatric Registrar.

Note: Hypothermia is often the first sign of sepsis and the possibility of major infection should always be considered.

Sepsis Risk Factors at Delivery

• Prolonged rupture of membranes
• Gestation <37 weeks
• Maternal pyrexia
• Fetal tachycardia
• Offensive liquor (meconium exposure)

Take swabs at delivery (ear/axilla/gastric aspirate) and ask for a differential on a full blood count. Request AC temperature and respiratory recordings.

If the white blood count shows a left shift (band forms and immature forms >20% of total neutrophils), if the respiratory rate is >60/minute or the temperature is >37.5°C, or swabs subsequently grow Group B Streptococcus refer to the Paediatric Registrar.

If two or more risk factors present, or the baby has symptoms other than the above, immediate referral is necessary.

Risk Factors for Group B Streptococcal Sepsis

• PROM
• Prematurity
• Amnionitis
• Previously affected infant
• Twins
• Known GBS colonisation

If mother has any of these risk factors then the guidelines for NWH suggests antibiotics in labour.

Jaundice

(see also Neonatal Jaundice on the Postnatal Ward)

• Jaundice requires Paediatric evaluation in the following situations and whenever there is a possibility that hyperbilirubinaemia may be indicated or cause pathology:

1. Clinically present before 24 hours of age.
2. Whenever other symptoms/signs of illness are present.
3. When the serum bilirubin is >200mmol/L on the second day of life.
4. When the serum bilirubin is >250mmol/L.
5. When jaundice is of late onset (7-10 days or later) or is prolonged with serum bilirubin >200mmol/L after 7-10 days of life.

• If a jaundiced baby requires phototherapy then a Paediatric referral and assessment is mandatory.
• At the time of Paediatric referral, a request should be made to blood bank for the baby's blood group and Coomb's results.
• A full blood count and film comment is also helpful at this stage, but may await a Paediatric assessment.

Heart Murmurs

• If the baby is well then a chest x-ray and ECG should be carried out and then referral to a Paediatric registrar should be undertaken.
• If the baby is tachypnoeic, cyanosed, or unwell, the baby should be referred immediately to the Paediatric Registrar.

Cord Flare

• This may indicate the presence of early omphalitis although commonly is due to cord-clamp irritation of abdominal skin.
• If there are no other signs of sepsis (fever, tachycardia, paronychia, skin pustules elsewhere or induration), check FBC, do umbilical and groin swabs, and observe.
• If other signs of sepsis are present, refer to Paediatric Registrar immediately for full septic screen and treatment.