Oxford Handbook of Midwifery (126 page)

If a baby in an incubator becomes cold

If still cold after 1h:

General points

Cot-nursed babies who become cold

1. Fleming PJ, Blair PS, Bacon C,
   et al
   . (1996). Environment of infants during sleep and risk for SIDS: Results of 1993–1995 case centred study for confidential enquiry into stillbirths and deaths in infancy.
   British Medical Journal
   313
   (7051), 191–5.
   
2. Fellows P (2001). Management of thermal stability. In: Boxwell G (ed.)
   Neonatal Intensive Care Nursing
   , 2nd edn. London: Routledge.
   
3. Bailey J (2000). Temperature measurement in the preterm infant: a literature review.
   Journal of Neonatal Nursing
   6
   (1), 28–32.
   

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   Care of the newborn
   

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   Hypoglycaemia
   

   Healthy term newborns who are breastfeeding on demand
   need not
   be screened for hypoglycaemia and need no supplementary foods or fluids. They do not develop ‘symptomatic’ hypoglycaemia as a result of simple underfeeding.
   

   Babies at high risk of hypoglycaemia can be identified as follows:
   

   • Preterm baby <37 weeks
     
   • Weight <2.5kg
     
   • Apgar <5 at 1min and/or <7 at 5min
     
   • Fetal blood sample pH <7.2
     
   • Umbilical venous/arterial pH <7.1.
     

     If a baby meets one or more of the above criteria the following protocol is instigated.
     

     1. Breastfeed and give skin-to-skin contact as soon as possible after birth.
        
     2. 2h post delivery, blood glucose analysis required.
        
     3. Then 3h feeds and pre-feed blood glucose analysis for 12h.
        
     4. Discontinue blood glucose analysis after 12h if pre-feed results are at/ or >2.6mmol/L.
        
     5. Continue 3h feeds and assessment of vital signs for 24h.
        
     6. Document results and actions taken.
        
   • If the baby fails to feed at 3h intervals assist the mother to express her milk.
     
   • Offer expressed breast milk (EBM) obtained via cup/pipette.
     
   • Leave baby to rest.
     

     •
     After 24h if baby is well, extend feeds to 3–4h, then introduce demand feeding as tolerated.
     

   • Assess baby’s vital signs and feeding at each shift until transfer to community.
     
   • Infants of diabetic mothers (insulin dependent or gestational diabetic) require active management.
     
   • 30min post delivery, blood glucose analysis required, then offer baby a breastfeed irrespective of result.
     
   • If baby fails to feed well, offer any EBM obtained with additional formula milk if required.
     
   • The baby must receive as much milk as possible but at least 5mL/ kg birthweight should be given. The total volume taken should be controlled by the baby’s appetite.
     
   • Then 3h feeds, pre-feed blood glucose analysis, and assessment of vital signs for 24h.
     
   • Discontinue blood glucose analysis after 24h if pre-feed results are at/ or >2.6mmol/L.
     
   • Document results and actions taken.
     

1. • If pre-feed blood glucose analysis is <2.6mmol/L inform paediatrician.
     
   • Offer baby a breastfeed. If baby fails to feed well, offer any EBM obtained with additional formula milk if required.
     

HYPOGLYCAEMIA

593

<2.6mmol/L, baby requires paediatric assessment.

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Care of the newborn

594‌‌

Advice to parents: reducing the risk of sudden infant death syndrome

Cot death, or SIDS, is the sudden unexpected death of an apparently well baby aged from birth to 2 years. Over 300 babies still die of cot death a year in the UK. The UK rate was 0.55/1000 live births in 2007.
¹

Although there is no guaranteed method of preventing cot deaths the risk can be reduced by following Department of Health and Foundation for the Study of Infant Deaths (FSID) guidelines.
²
This leaflet should be given to and discussed with all new mothers prior to taking a baby home from hospital. Since parents and carers have been following the risk reduction advice, the number of babies dying has fallen by over 70%. Health professionals can explore the research behind the recommendations by downloading a fact file from the FSID website.
³

2 The recommendations that should be given to parents are as follows.

• Place your baby on their back to sleep, in a cot in a room with you.
  
• Do not smoke in pregnancy or let anyone smoke in the same room as the baby.
  
• Do not share a bed with your baby if you have been drinking alcohol, if you take drugs or if you are smoker.
  
• Never sleep with your baby on a sofa or armchair.
  
• Do not let your baby get too hot. Keep your baby’s head uncovered. Their blanket should be tucked no higher than their shoulders.
  
• Place your baby in the feet to foot position (with their feet at the end of the cot or pram).
  

  Other factors that can help reduce the risk
  ⁴
  are:
  

  •
  Breastfeeding.
  

• Keeping the baby in the same room as the parents for the first 6 months.
  
• Using sheets and lightweight blankets. Do not use duvets, quilts, pillows or similar thick bedding.
  
• Keeping the bedroom at a comfortable but not hot temperature (18°C).
  
• The baby should never sleep with a hot water bottle or next to a radiator, heater, or fire, or in direct sunlight.
  
• Using a dummy but if breastfeeding do not give the baby a dummy until they are 1 month old.
  
  1. Foundation for the Study of Infant Deaths (2009).
     Cot Death Facts and Figures
     . London: FSID. Available at: M
     http://fsid.org.uk/Document.Doc?id=42 (accessed 3 April 2010).
     
  2. Department of Health (2009).
     Reduce the risk of Cot Death
     . London: DH and FSID.
     
  3. Foundation for the Study of Infant Deaths (2009).
     Factfile
     ²
     : Research Background to the Reduce the Risk of Cot Death Advice from the Foundation for the Study of Infant Deaths
     . London: FSID. Available at: M http://fsid.org.uk/factfi
     le_2 (accessed 3 Aril 2010).
     
  4. National Health Service (2009).
     Cot Death: How to Reduce the Risk
     . London: NHS. Available at:
     

  M
  www.nhs.uk/livewell/childhealth0-1/pages/cotdeath.aspx (accessed 3.4.10).
  

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  Bed sharing
  

  Bed-sharing is a controversial issue and has been linked to cot deaths. Many mothers will take their babies into bed to feed and provide comfort without intending to fall sleep. Bed sharing has been shown to promote breastfeeding, therefore it is important that midwives give the mothers the correct information to enable mothers continue breastfeeding, while at the same time reducing the risk of cot death.
  ¹
  

  Recommendations while in hospital
  

  2 Mothers should be constantly supervised if bed sharing and co-sleeping if they are:
  

• Under the effects of a general anaesthetic
  
• Immobile due to a spinal anaesthetic
  
• Taking drugs that may cause drowsiness
  
• Seriously ill, e.g. high temperature, large blood loss, severe hypertension
  
• Excessively tired
  
• Have a condition that affects mobility, sensory, or spatial awareness,
  

  e.g. multiple sclerosis, blindness
  

• Very obese
  
• Likely to have temporary loss of consciousness, e.g. if she is diabetic or epileptic.
  

  Bed sharing and co-sleeping is contraindicated if:
  

• A mother is a smoker
  
• The baby is preterm or ill.
  

  Advise to mothers at home
  

  Mothers should always be given the UNICEF leaflet ‘Sharing a bed with your baby’ prior to transfer home.
  ²
  It is recommended that babies share their mother’s room for at least the first 6 months, as this assists breast- feeding and protects against cot death.
  

  When mothers should not sleep with their babies
  

  If they or their partners:
  

• Are smokers
  
• Have drunk alcohol
  
• Have taken any drug (legal or illegal) which makes them drowsy
  
• Have a condition that affects their awareness of their baby
  
• Are overtired to the point that they could not readily respond to their baby.
  

  Reducing the risk of accidents and overheating
  

• Parents should
  never
  sleep with their baby on a sofa or armchair.
  
• The bed must be firm and flat.
  
• Ensure the baby can not fall out of bed or get stuck between the mattress and wall.
  
• Make sure the room is not too hot (16–18°C is ideal).
  
• The baby should not be overdressed.
  
• Bedclothes must not overheat the baby or cover the baby’s head.
  
• Never leave the baby alone in or on the bed.
  
• The partner should be informed if the baby is in bed.
  

  BED SHARING
  

  597
  

Mothers who are bottle feeding should be advised to put their babies back into their cot after feeding, as mothers who bottle feed can sometimes turn their backs on their babies when they have fallen asleep.

1. UNICEF UK Baby Friendly Initiative (2004).
   Babies Sharing their Mothers Bed while in Hospital: A Sample Policy
   . London: UNICEF UK Baby Friendly Initiative. Available at: M www.babyfriendly.org.
   uk (accessed 5.1.11).
   
2. UNICEF/Foundation for the Study of Infant Deaths (2008).
   Sharing a Bed with Your Baby:
   

   A Guide for Breastfeeding Mothers
   . London: UNICEF UK Baby Friendly Initiative. Available at:
   

   M www.babyfriendly.org.uk/pdfs/sharingbedleaflet.pdf
   

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   Neonatal infection
   

   The incidence of infection in the newborn has declined over the past 10 years due to the increased use of antenatal antibiotics and more effective management of premature rupture of the membranes.
   ¹
   

   Definitions
   

   • Very early onset: <24h.
     
   • Early onset: 1–7 days.
     
   • Late onset: >7 days.
     
   • Nosocomial infection: hospital acquired.
     
   • Bacteraemia
     :
     the presence of viable bacteria in the blood.
     
   • Septicaemia: systemic disease caused by the multiplication of organisms in the blood.
     
   • Sepsis: the presence of pus-forming and other pathogenic organisms in the blood.
     ¹
     

     Infections acquired in the antenatal period
     

     Amniotic fluid has bactericidal properties and the membranes provide a physical barrier. If these defences are breached, the fetus will be infected by direct aspiration into the lungs, causing pneumonia and bacteraemia.
     

   • GBS is the most common cause of early-onset septicaemia and meningitis.
     
   • Mycoplasmas found in the maternal genital tract can cause premature labour.
     
   • GBS and mycoplasmas have also been found where the membranes remain intact.
     

     Other organisms that ascend the genital tract and contaminate the
     

     amniotic fluid are:
     

   • Bacteroides
     spp.
     
   • Escherichia
     coli
     
   • Clostridium
     spp.
     
   • Peptococcus
     spp.
     

     Infections acquired via the placenta
     

   • Listeria monocytogenes
     causes placentitis.
     
   • Viruses, such as cytomegalovirus, herpes, and that causing rubella, and the parasitic protozoan
     Toxoplasma
     sp., also affect placental function, resulting in growth retardation and congenital abnormalities.
     
   • Intrauterine infection with parvovirus B19 is associated with fetal anaemia.
     
   • Vertical transmission of HIV from the mother to the fetus through the placenta is thought to be related to the maternal viral burden, disease stage, and immune response.
     

     Intrapartum infection
     

     Factors that increase the likelihood of intrapartum infection are:
     

   • Premature labour
     
   • Maternal pyrexia
     
   • Prolonged rupture of the membranes.
     

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599

Causative organisms include: