Criteria for attendance at delivery by neonatal staff

Communication around an emerging situation where there may be both neonatal and maternal concerns is a challenge, however every effort should be made to ensure that adequate information is accurately passed to the neonatal team when they are called for resuscitation.  Ideally the call should be made by a member of staff with a good working knowledge of the situation- if the midwife looking after the mother or midwife in charge is not able to make the call to the neonatal team, they should ensure that when delegating this adequate information is passed on.

When calling for neonatal assistance, the SBAR format should be used:

Deliveries not routinely requiring the presence of neonatal staff:

• Elective caesarean sections under regional anaesthesia with no concerns re fetal wellbeing
• Low/mid cavity instrumental deliveries with no concerns re fetal wellbeing

First Attender only (Doctor or ANNP carrying the first-on page)

• 33-36 weeks gestation
• Where a fetal blood sample (FBS) has been done with a pH <7.25
• Intrapartum haemorrhage prompting delivery*
• Fresh meconium in the amniotic fluid, with an abnormal CTG or FBS*
• Vaginal breech delivery*
• Instrumental deliveries in theatre
• Sustained Fetal tachycardia > 160
• Non-reassuring CTG *

All those marked with a * require assessment by labour ward staff of the degree of concern and whether middle grade staff should be requested to attend in addition to the first attender.  This should be communicated using standard SBAR procedures

First Attender and Middle Grade (Doctor or ANNP carrying the second-on page)

• Caesarean Section under general anaesthesia
• All criteria above marked * where labour ward staff have sufficient concerns
• All emergency calls (2222 calls)
• 29-32 weeks’ gestation
• Major concerns re intrapartum fetal wellbeing, e.:
  • Significant abruption
  • Any case of suspected fetal haemorrhage (specify this concern to neonatal team)
  • Acute fetal bradycardia
  • Cord prolapse
  • Shoulder dystocia
  • FBS with pH <7.2
• Multiple births <37 weeks
• Fetal anomalies with potential need for immediate resuscitation/stabilisation, e.g.
  • Duct dependent cardiac anomalies } A delivery plan should be agreed antenatally.
  • Cleft lip/palate                                     } This should include a decision about the staff 
  • Abdominal wall defects                     } required at delivery.  This may include the need for
  • Open Spinal defects                           } the presence of a consultant or other specialist.

First Attender, Middle grade and Consultant

(A sufficiently experienced neonatal trainee may act up in the role of the Consultant by agreement with the attending consultant)

• <29 weeks’ gestation
• Diaphragmatic hernia
• Hydrops fetalis
• Fetal anomalies with potentially immediate life threatening consequences.
• CTG trace suggestive of fetal asystole or severe bradycardia

It should be borne in mind that consultant staff are not resident out of hours in all units, and are not ordinarily part of the paediatric emergency team.  It is the responsibility of the middle grade on call to have accurate contact information for the on call consultant.  This may be in the form of a “baton” page or a list of contact numbers.

There are also a number of circumstances where a team including specialists other than neonatologists should attend delivery, e.g. ENT support for congenital upper airway anomalies. This should be clearly documented in the maternal notes, and the on call neonatal team should be informed as soon as a mother presents in labour.

Attendance by neonatal nursing staff

• Attendance by neonatal nursing staff is determined in part by local arrangements for cover with labour ward.
• In all cases requiring a registrar or consultant a member of the neonatal nursing team should also attend as admission to the neonatal unit would be expected.
• Where nurses/midwives “taking the baby” at a caesarean section will be impinging upon the sterile field (e.g if baby going into a plastic bag, having delayed cord clamping etc), they should scrub and gown in the same way as those at the operating table.

A number of fetal/neonatal issues require prompt review by a member of the neonatal team after delivery, but do not require them to be present at delivery.  This is primarily to ensure that an investigation/treatment plan is put in place.  The neonatal team should be informed of these situations before delivery, and should review the babies before they leave labour ward.

Requiring prompt review:

• Maternal HIV infection – See Neonatal HIV guideline
• Maternal Hepatitis B infection – See Neonatal Immunisation guideline
• Known blood group sensitisation with haemolytic antibodies present (e.g. rhesus incompatibility) – See Neonatal transfusion guideline
• Risk factors for Early Onset Neonatal Sepsis – See Early Onset Sepsis guideline
• Infants at risk of hypoglycaemia – See Neonatal Hypoglycaemia guideline
• Infants at risk of bleeding, e.g. maternal haemophilia carrier, ITP or NAIT
• Other situations where an urgent neonatal review has been requested in the special features section of the maternal notes.

There are a number of situations outwith this that merit review by the neonatal team in the postnatal period, but where there is no need for any intervention immediately, e.g. an infant with antenatally diagnosed renal pelvis dilatation.  In these circumstances it is most appropriate that the baby is reviewed on the postnatal ward, and many can wait for normal working hours.  As before if there is any doubt about the timing of a review please contact the neonatal team to discuss.