Paarl Hospital Neonatal Care: General Information

Meetings/Clinics

Morning duties

Afternoon duties

Students rotating through the nursery

Infection control policy

Admission criteria

Discharge policies

The neonatal service consists of 14 neonatal beds and 6 KMC beds (2B2) as well as the problematic babies from the 22 bed rooming-in ward (2B1). We do not have any NICU beds and inadequate staffing to run a high care facility currently. 

Meetings/Clinics

Perinatal problem identification M+M’s are held on the first Friday of every month 7:30 in the boardroom. High risk clinics are held once a month in POPD on a Monday. Please book during office hours at ext. 3097. After hours/weekends, enter patient details and appointment date into POPD notebook kept in nursery. Uncomplicated follow-ups eg for weight gain can be booked for general POPD clinic. 

Morning duties

Hand-over at 8:00 in the nursery. Doctor on call for caesarean sections should be allocated (labour ward and switch board to be informed). Allocated doctor to start the day with check of resuscitation area, Neopuff in theatre and report all shortcomings to Mrs Le Roux in theatre. All patients to be seen before 11:00 ward round if possible. (That includes problem babies from ward 2B1 - get names from 2B1 ward round book). Bloods and procedures to be completed after ward rounds. Discharge summaries and TTO’s to be ordered for babies that can be discharged as well as transfer arranged for patients transferred to step down facilities. 

Afternoon duties 

Check and enter all results on individual patient result sheets. Act or ask advice on abnormal results. Review and sign off on all print outs of results sent from the lab to the nursery after which they should be handed over to the ward clerk for filing. Review all the red flagged patients from the morning. Check all IVI lines are in working condition before handing over to the on call doctor. Handover is usually around 15:45. 

Always include mothers in the evaluation of the baby. Discuss progress and feeding problems where appropriate. 

Most junior doctor allocated to the nursery should attend the elective Caesarean section list on a Friday morning and Tuesday afternoon. Check resuscitation equipment in theatre before the list starts and report any missing or faulty equipment to theatre sister Le Roux. 

Before the weekend, make sure all potential discharge summaries are prepared on the computer, TTO’s ordered where possible, there is enough paper in the folder for writing notes and all prescription charts have enough space to last until the Monday/next working day in case of long weekend. 

Students rotating through the nursery

Paarl Hospital is a training hospital. It is part of our responsibilities to develop students and junior staff. The more people know what to do, the better the patient care and the lighter the workload! 

Medical students: 4th year students from TBH rotate through the nursery. Please familiarize them with hand washing techniques and allow them each to see at least 2 stable babies. Babies should be presented to one of the doctors in the nursery, clinical findings confirmed as well as management plan including feeds/fluid volumes/drugs checked. 

Paramedic students: Please familiarize them with hand washing techniques. A list of their responsibilities in the nursery plus notes for them to read is available in the nursery. A short tutorial on neonatal transport and UVC placement will be given to them by the ward consultant if compatible with the clinical work load. 

Nursing students: Please assist where appropriate with advice and training. 

Infection control policy

Universal precautions 

• Everyone entering the nursery should wash their hands immediately on arrival. 
• Hand decontamination is the single most important preventative measure for preventing cross infection. This could be achieved through hand washing or use of hand rubs. 
• Wash your hands using long acting antiseptic detergent such as chlorhexidine hand scrub. Wash your hands for at least 20 seconds, washing your palms, back of your hands, web spaces, fingers including thumbs and tips of your fingers. 
• Use chlorhexidine-based alcohol rub, e.g. D-germ before each infant is examined. Ensure all surfaces of your hands are wet with D-germ. Rub your hands together in the same manner as for hand-washing until the hands are dry. In the absence of secretions contaminating your hands, use of hand-rub is as effective as hand-washing. 
• Use the stethoscope allocated to each individual patient for that patient only. In the absence thereof, wipe your stethoscope with an alcohol swab before each patient. 
• All invasive procedures must be performed under sterile conditions, using sterile gloves, masks, a sterile gown and sterilized equipment. 
• Do not bring your personal bags into the ward. 
• Remove wrist watches and rings. 
• No nail polish allowed 
• Roll up your sleeves if wearing clothes with long sleeves before examining patients. Take overcoats off before entering the ward. 

Isolation 

• Infants infected with resistant organisms such as Acinetobacter, ESBL producing bacteria, MRSA, Fungi/candida must be isolated in the isolation cubicle. Also infants with diarrhoea or suspected viral infection with RSV. 
• If the isolation cubicle is not available, the patient can be nursed in a corner within a strictly demarcated area using relevant precautions. 
• Non-sterile, clean gloves must be used when examining these patients and must be discarded immediately after examining the patient. 
• A stethoscope must be allocated to each isolated infant. Do not use your own stethoscope. 

Admission criteria 

Babies to be admitted in nursery ward 2B2 

• Respiratory Distress eg RDS/TTN/cong pneumonia 
• MSL with respiratory distress 
• Suspected moderate and severe HIE (Apgar at 5 min <5/10 or active resuscitation still required at 5 minutes of age) 
• Severe congenital abnormalities 
• Blood group incompatibility (Rh neg mothers and O+ mothers) 
• Prolonged rupture of membranes in infants <37 weeks or symptomatic infants 
• Foul smelling liquor and symptomatic baby 
• Babies of mothers with chorio-amnionitis 
• Neonates <1800g or <35 weeks gestation 
• Neonates with recurrent hypoglycaemic episodes in 2B1 

Babies to be monitored in 2B1 

1. HGT – IDM, babies 1800-2000g/>4kg, babies that needed resuscitation at birth 
2. Vacuum deliveries for 6hrly Hb and H/C monitoring 
3. Asymptomatic babies on antibiotics 
4. Uncomplicated neonatal jaundice for phototherapy 
5. Minor congenital abnormalities 

Infants qualifying for KMC must meet the following criteria 

1. >1400kg 
2. On full maternal breastmilk (no formula or donor EBM) 
3. Not needing nasogastric tube 
4. Maintaining temperature for 24hrs in crib 
5. Ward Hb ≥7g/dL 

Discharge policies 

Infants qualifying for discharge from nursery 

• Ensure antenatal blood results are available (Rh,WR and HIV) and acted upon. 
• Ensure that infant is well, acute medical illnesses has resolved, baby passed urine and stool, is feeding well and has no jaundice. 
• Those admitted for glucose monitoring should have normal glucose levels (≥2.5mmol/l) for at least 12hrs before discharge. 
• Weight must be at least 1800g before discharge. 
• Infants born to mothers with TB should be worked up according to protocol (see TB exposed neonate: management guideline) 
• Each infants details must be included in the Paarl Paeds program for statistics. 
• A short note should be made in the RTHC. 
• Ensure neonate had all the appropriate immunisations before discharge.