• For use at Wexham Park and Frimley Park Hospitals.

• Admission to the Neonatal Unit may be anticipated or unanticipated.

• Good communication between Maternity and Neonatal staff can help identify babies requiring admission promptly.

• Babies are usually admitted from Labour Ward, Birth Centre or Postnatal Ward. However, in some circumstances, they may be admitted from outside the hospital including home (e.g., following delivery at home), the Emergency Department or transferred from another hospital.

• This guideline includes clinical admission criteria for admission to the Neonatal Unit.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use

Abbreviations

The Neonatal Units (NNU) at Wexham Park and Frimley Park Hospitals provide neonatal special and intensive care (Level 2, Local Neonatal Unit). Admissions to the NNU can be planned or take place in an emergency; admissions usually occur from Labour Ward, Birth Centre or the Postnatal Ward. However, it is possible that a baby will need to be admitted following a home birth or transfer from another hospital (usually a repatriation) or from Emergency Department.

Regular communication between Maternity and Neonatal Unit Staff will ensure smooth running of both Units. The Nurse in Charge on the NNU and the Labour Ward Co-ordinator on Labour Ward should discuss potential admissions to the NNU after each handover and inform the Neonatal Senior Resident Doctor (Registrar). Some admissions to the NNU can be anticipated; for instance, those identified at the Fetal MDT meeting (Wexham Park Hospital) or those identified antenatally will be highlighted at the daily safety hub meeting (Frimley Park Hospital).

The Neonatal Junior Resident Doctor (SHO) should be informed if a baby shows any abnormal signs or symptoms. The Neonatal Junior Resident Doctor may identify some babies requiring admission to NNU when they attend a delivery or review a baby. (N.B. neonatal attendance at deliveries is not covered in this guideline). Once the baby has been assessed and admission is felt necessary, it must be discussed with the Neonatal Senior Resident Doctor (Registrar) and Nurse in Charge on the NNU and the Midwife looking after the baby.

If Labour Ward receives a referral from an outside unit for an in-utero transfer of a premature baby or baby that will likely need admission to the NNU once delivered, the Labour Ward Co-ordinator should discuss with the Neonatal Team (which may need to include Neonatal Consultant depending on the case). If Labour Ward is unable to accept the referral, this must be discussed with the Labour Ward Co-ordinator and consider discussion with the Obstetric Consultant and Neonatal Consultant on-call, and should be documented in the daily diary. Similarly, the NNU will also keep a record of any in-utero or ex-utero referrals, and any ex-utero refusals should first be discussed with the Neonatal Consultant.

Transfer the baby to the NNU in a cot, with a warming mattress if needed, unless the baby requires oxygen. In the latter case, the transfer should be made using the resuscitaire or the Giraffe Incubator with shuttle (preferred option for premature babies) or transport incubator.

Please ensure the baby has 2 identification labels and update the parents regarding the need for admission.

Aim to stabilize the baby as much as possible before transfer. Use saturation and temperature probes during transfer where available/appropriate.

Ensure a helper runs ahead to hold open double doors to minimize time spent in cold corridors or lifts. Keep baby warm during transfer, see Neonatal Thermoregulation.

• Transfers from home: for a baby identified to have problems at home birth, transfer should be arranged by the midwife attending the birth. A paramedic ambulance should be used.

Babies less than 5 days of age may, if appropriate, be re-admitted to NNU from home. In some circumstances, e.g., jaundice requiring multiple phototherapy or exchange-transfusion, the cut-off age for re-admission may be extended to 10 days.

• Transfers from other hospitals (usually repatriations) should be planned in advance and should have been discussed with the Neonatal Consultant and Nurse in Charge on the NNU.

In either case, the Neonatal Resident Doctors, and allocated nurse should take handover from transfer staff. The Neonatal Consultant on duty should be informed.

• Prematurity:

  • Babies less than 34 weeks' gestation (babies 34 weeks gestation or more may be cared for on Transitional Care in Postnatal Ward)

  • Low birth weight: babies less than 1700g

  • Persistent hypothermia despite appropriate measures, see Neonatal Thermoregulation.

• Post prolonged resuscitation

  • With abnormal clinical examination

  • Requiring on-going cardiovascular or respiratory support

  • Concerns of HIE - see Therapeutic Hypothermia guideline (Wexham Park TV&WNN site, Frimley Park https://ashfordstpeters.net/neonatalguidelines/)

• Respiratory problems

  • Persistent grunting/tachypnea/low oxygen saturations

  • Recurrent or prolonged apnoeic or cyanosis episodes

  • Requirement of any form of respiratory support

• Infection

  • Suspected sepsis with clinical signs

  • Postnatal collapse

• Gastrointestinal problem

  • Bilious vomiting

  • Significant abdominal distension/persistent

  • Jaundice requiring more than double phototherapy, likely exchange transfusion or rapidly rising SBR requiring monitoring more frequently than 4-hourly, see Neonatal Jaundice.

• Metabolic

  • Hypoglycemia requiring frequent tube feeds or intravenous fluids, see Neonatal Hypoglycaemia (Management on Maternity Wards) and Neonatal Hypoglycaemia (Management on NNU).

• Cardiovascular

  • Suspicion of significant cardiac abnormality

• Neurological

  • Seizures or any abnormal neurological signs

  • Grade 2 or 3 hypoxic-ischemic encephalopathy (HIE) see Therapeutic Hypothermia guideline (Wexham Park TV&WNN site) Frimley Park https://ashfordstpeters.net/neonatalguidelines/)

  • Signs of Neonatal Abstinence Syndrome requiring treatment (Wexham Park TV&WNN site) (Frimley Park https://ashfordstpeters.net/neonatalguidelines/)

• Major congenital anomalies/ abnormalities causing physiological instability

• Any baby that requires close and continuous monitoring

Avoid unnecessary separation of baby from mother

Details of any unanticipated admission to the NNU should be collected on an In Phase report by maternity staff and discussed at the Patient Safety and Quality meeting (PSQ).

Some of these cases will require discussion at the monthly Perinatal Morbidity and Mortality Meetings; trends and problems identified should be discussed at the Maternity Forum. These meetings are multi professional and minutes are recorded, action plans are agreed and there is follow-up at subsequent meetings.