of Paediatric Problems on Postnatal Wards by Obstetric House Staff and
|Reviewed by Salim Aftimos
The following are some guidelines
and list of conditions which may be managed by obstetric house staff and Lead
Maternity Carers on
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.
- 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
- 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.
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.
- These babies are at risk of
- 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.
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
- 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
- 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
- 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.
- 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
- Temperature instability after
the first day should be referred to the Paediatric Registrar.
Hypothermia is often the first sign of sepsis and the possibility of major
infection should always be considered.
Risk Factors at Delivery
- Prolonged rupture of
- Gestation <37 weeks
- Maternal pyrexia
- Fetal tachycardia
- Offensive liquor (meconium
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
Factors for Group B Streptococcal Sepsis
- Previously affected infant
- Known GBS colonisation
If mother has any of these risk
factors then the guidelines for NWH suggests antibiotics in labour.
(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:
- Clinically present before
24 hours of age.
- Whenever other
symptoms/signs of illness are present.
- When the serum bilirubin is
>200mmol/L on the second day of life.
- When the serum bilirubin is
- 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
- 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
- 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