Nottingham Neonatal Service - Clinical Guidelines Guideline No A2

Title: Indications for Calling a Neonatal Team to Delivery

Suite
Version: 6
Ratification Date: Feb 2014
Review Date: Feb 2017
Approval: Nottingham Neonatal Service Clinical Guideline Meeting
Author: Sara Watkin. (Reviewed November 2003, 2014 by Stephen Wardle)
Job Title: Consultant Neonatologist.
Delivery suite and postnatal ward midwives, neonatal staff.
Consultation:
Guideline Contact Dr Stephen Wardle, Guideline Coordinator and Consultant
Neonatologist co/ Stephanie Tyrrell, Nottingham Neonatal Service
stephanie.tyrrell@nuh.nhs.uk
Distribution: Nottingham Neonatal Service, Neonatal Intensive Care Units,
Midwifery Managers
Target audience: Staff of the Nottingham Neonatal Service and Maternity Service
Patients to whom Patients of the Nottingham Neonatal Service who fit the inclusion
this applies: criteria of the guideline below
Key Words: NICU, neonatal team
Risk Managed: Appropriate personnel available to provide neonatal resuscitation
Evidence used: The contemporary evidence base has been used to develop this
guideline. References to studies utilised in the preparation of this
guideline are given at its end.

Clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior
colleague. Caution is advised when using guidelines after the review date. This guideline has
been registered with the Nottingham University Hospitals NHS Trust.

1. Introduction

All professionals caring for mothers in the labour ward must be able to instigate neonatal face-mask
ventilation as part of basic resuscitation. Individuals must also be available who can provide
advanced neonatal resuscitation. A neonatal SHO or an Advanced Neonatal Nurse Practitioner
(ANNP) will be available at all times to undertake this role. A more senior member of staff either a
Registrar or Consultant Neonatologist will also be available at all times to attend for more complex
problems.

2. Communication

2.1 The SHO in Obstetrics / Midwifery Co-ordinator will contact the neonatal practitioner (SHO
or ANNP) on call for the Labour Suite and discuss cases where they may be needed at
delivery (see section 3 below). The SHO in Obstetrics / Midwifery Co-ordinator will also,
where indicated, inform the Neonatal Unit Co-ordinator.

2.2 Two neonatal unit staff (usually to include the Registrar or Consultant) should be called for :-
• Multiple births <34 weeks
• Singletons ≤ 30 weeks
• Where an infant may need urgent invasive care (e.g. congenital diaphragmatic hernia,
hydrops fetalis)
• When there is a persistent fetal bradycardia (HR<60) resulting in an Emergency (Grade
1 at QMC, Category RED at CHN) Caesarean Section.

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2.3 A neonatal nurse should also ideally attend deliveries where admission of the infant to the
neonatal unit is expected i.e. less than 32 weeks gestation or where the infant is known to
have a surgical condition requiring admission e.g. gastroschisis, diaphragmatic hernia.

The role of the Neonatal Nurse on Delivery Suite will be to assist the SHO / ANNP /
Registrar with the resuscitation. The neonatal nurse will routinely assist with temperature
maintenance (use of plastic bag wrapping and hat etc), fixation of the ETT, identification
labelling and communication with the parents. During a complicated resuscitation the
Neonatal Nurse may need to help with other aspects of the resuscitation such as cardiac
compressions, assisting with airway control in a ventilated baby, or assisting with the
insertion of an umbilical venous catheter. Following resuscitation and communication with
the parents he / she will also assist with the transport of the baby to the NICU on the
resuscitaire and then be responsible for the baby’s admission to the NICU.

2.4.1 The Neonatal SHO / ANNP or the Obstetric Registrar / Consultant may additionally request
the presence of the Neonatal Registrar / Consultant at some high-risk deliveries.

2.4.2 The Neonatal Consultant should, if possible, be aware of and be involved in the
management plan for the resuscitation and initial management of extremely preterm infants
(< 26 weeks) before the delivery. If the delivery is planned the Consultant should be
informed in sufficient time so that they can be present if appropriate.

2.6 In an emergency the midwife in charge or her deputy should call the neonatal practitioner on
call for labour suite. The reason for being called and the degree of urgency should be
discussed.

3. Indications for a neonatal practitioner to attend a delivery

• Fetal compromise (as assessed by the obstetrician / midwife e.g. pathological CTG, pH on FBS
< 7.2, Apgar score < 5 at 1 minute)

• Meconium-staining of the liquor

• Urgent (Grade 2) or emergency (Grade 1) Caesarean Section

• Elective caesarean section under general anaesthesia or for placenta praevia, multiple births or
where admission to the neonatal unit is likely. It is inappropriate to call the SHO for routine
attendance at elective LSCS under regional anaesthesia where the indication for delivery is:-
• Previous LSCS / CPD [1,2]
• Breech / transverse or unstable lie

• Vaginal Breech delivery

• Multiple pregnancy

• Rotational forceps (e.g. Keilland's forceps) delivery

• Preterm delivery at less than 34 weeks gestation

• Severe intrauterine growth retardation

• Maternal insulin dependent diabetes

• Maternal myasthenia gravis

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• Known serious fetal abnormality e.g. diaphragmatic hernia, hydrops fetalis

• Severe rhesus disease likely to require neonatal intensive care.

4. Audit points

4.1 Routine data collection

Number (percentage) of deliveries attended by Practitioner / SHO / Registrar.

4.2 Specific audit points

Number of newborn babies requiring advanced resuscitation by mode of delivery, risk factor etc.

5. Allied Guidelines

Neonatal Guideline A3 Indication for admission to the neonatal medical and surgical unit.

6. References
1. Levine EM et al Obstetrics and Gynecology 1999;93(3):338-340
2. Jacob J et al Obstetrics and Gynecology 1997;89(2):217-220

7. Summary Box and Levels of Evidence

Level of Evidence
Two neonatal unit staff should be called for complex deliveries D
A neonatal nurse should attend deliveries of preterm infants D
A neonatal practitioner is not required for an elective C Section under C
regional anaesthesia [1,2]