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Postnatal care
Short Text
Introduction
The postnatal care pathway covers the essential core (routine) care that every woman and her baby should receive in the first 6–8 weeks after birth, based on the best evidence available.
Although for most women and babies the postnatal period is uncomplicated, care during this period needs to address any deviation from expected recovery after birth. This pathway gives advice on when additional care may be needed and these recommendations have been given a status level (indicating the degree of urgency needed in dealing with the problem) as follows:
Emergency – life-threatening or potential life-threatening situation
Urgent – potentially serious situation, which needs appropriate action
Non-urgent – continue to monitor and assess.
The pathway includes information about risk factors and inspection for neonatal jaundice and the quality standard on specialist neonatal care. It also covers recommendations from the NICE public health guidance on maternal and child nutrition, which support improvements in the nutrition of breastfeeding mothers and babies beyond the immediate postnatal period. This includes encouraging breastfeeding exclusively for 6 months and supporting women to continue breastfeeding for as long as they choose.
Source guidance
The NICE guidance that was used to create the pathway.
Postnatal care. NICE clinical guideline 37 (2006)
Neonatal jaundice. NICE clinical guideline 98 (2010)
Maternal and child nutrition. NICE public health guidance 11 (2008)
Division of ankyloglossia (tongue-tie) for breastfeeding. NICE interventional procedure guidance 149 (2005)
Quality standards
Specialist neonatal care quality standard
These quality statements are taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statements
Care pathways and guidelines
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
In-utero and postnatal transfers for neonatal special, high-dependency, intensive and surgical care follow perinatal network guidelines and care pathways that are integrated with other maternity and newborn network guidelines and pathways.
Quality measure
Structure
(a) Evidence of perinatal network guidelines and care pathways for in-utero and postnatal transfers for neonatal special, high-dependency, intensive and surgical care.
(b) Evidence that perinatal network guidelines and care pathways for in-utero and postnatal transfers for neonatal special, high-dependency, intensive and surgical care, are integrated with other maternity and newborn network guidelines and pathways.
(c) Evidence of network arrangements to ensure that when a baby is admitted to specialist neonatal care, the mother and any multiple birth siblings can be accommodated in the same hospital during their respective admissions.
Process
(a) Proportion of babies born at less than 28 weeks of gestation who receive intensive care in a neonatal intensive care unit (NICU) within the network.
Numerator: the number of babies receiving intensive care in a NICU within the network.
Denominator: the number of babies born at less than 28 weeks of gestation within the network.
(b) Proportion of babies with antenatally diagnosed fetal malformations requiring early surgery who are delivered at a designated network surgical centre.
Numerator: the number of babies delivered at a designated network surgical centre.
Denominator: the number of babies born within the network with antenatally diagnosed fetal malformations requiring early surgery.
(c) Proportion of babies who are transferred back to their local neonatal unit within 24 hours of request for repatriation.
Numerator: the number of babies transferred within 24 hours of repatriation request.
Denominator: the number of babies transferred back to their local neonatal unit.
(d) Proportion of babies who require neonatal surgery who receive it at a designated network surgical centre.
Numerator: the number of babies undergoing surgery at a designated network surgical centre.
Denominator: the number of babies born within the network who require neonatal surgery.
(e) For singleton births: proportion of mothers who still require inpatient care when their baby is transferred to specialist neonatal care, who are transferred to the same hospital as their baby.
Numerator: the number of mothers transferred to the same hospital as their baby.
Denominator: the number of mothers who still require inpatient care when their baby is transferred to specialist neonatal care.
(f) For multiple births: proportion of babies transferred to specialist neonatal care whose mother and/or multiple birth siblings are transferred to the same hospital if still requiring inpatient care.
Numerator: the number of babies whose mother and/or multiple birth siblings are transferred to the same hospital.
Denominator: the number of babies from multiple births transferred to specialist neonatal care whose mother and/or multiple birth siblings still require inpatient care.
Description of what the quality statement means for each audience
Service providers ensure perinatal network guidelines and care pathways for transfers for neonatal special, high-dependency, intensive and surgical care are implemented and integrated with other maternity and neonatal guidelines and pathways. Ensure regular monitoring of operation and effectiveness.
Healthcare professionals ensure perinatal network guidelines and care pathways are followed when transferring babies for neonatal special, high-dependency, intensive and surgical care, and invoke a report or alert mechanism where this is not possible.
Commissioners and networks ensure all eligible patients within their health economy are covered by perinatal network guidelines and care pathways for transfer for special, high-dependency, intensive and surgical care.
Parents of babies transferred to neonatal special, high-dependency, intensive or surgical care can expect the transfer to be in line with network guidelines and care pathways. These guidelines and care pathways describe specific procedures about safely transferring babies to other hospitals.
Definitions
The Department of Health toolkit (2009) defines a network as 'linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a coordinated manner, unconstrained by existing professional and health board boundaries, to ensure equitable provision of high-quality, clinically effective services.'
Guidance on the content of guidelines and pathways can be found within the Department of Health toolkit (2009) under Principles 4 and 7.
Data source
Structure
Local and network data collection.
Process
Local and network data collection.
Annual needs assessments
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Networks, commissioners and providers of specialist neonatal care undertake an annual needs assessment and ensure each network has adequate capacity.
Quality measure
Structure
Evidence of an annual needs assessment including production of an annual report covering, as a minimum, specialist neonatal activity for the network's population, monitoring of quality metrics and how concerns are being addressed.
Process
(a) Proportion of mothers whose babies required specialist neonatal care and who were booked to deliver in the network who received all their perinatal care within the network area (standard 95% as per Department of Health toolkit [2009]).
Numerator: the number of mothers receiving all their perinatal care within the network area.
Denominator: the number of mothers whose babies required specialist neonatal care and who were booked to deliver in the network area.
(b) Proportion of babies who receive specialist neonatal care in the network who are from outside the network area.
Numerator: the number of babies from outside the network area.
Denominator: the number of babies receiving specialist neonatal care in the network.
(c) Bed occupancy for each level of care (standard 80% as specified in the Department of Health toolkit [2009]).
Description of what the quality statement means for each audience
Service providers cooperate with networks and commissioners to carry out an annual specialist neonatal care needs assessment. If service provision levels are found to be inadequate, they ensure action is taken in conjunction with commissioners.
Healthcare professionals assist with specialist neonatal care needs assessments by providing accurate and validated data.
Commissioners and networks ensure that, in conjunction with service providers, an annual specialist neonatal care needs assessment is undertaken. In addition, they clearly define expected levels of service provision.
Parents of babies receiving specialist neonatal care can expect that the needs of their baby will be met by services provided in their area.
Definitions
Quality metrics are defined further in the Department of Health toolkit (2009) section 5.
Data source
Structure
Local and network data collection.
Process
(a): Local and network data collection.
(b): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether all babies who access neonatal services are treated following their own neonatal network clinical pathway.
(c): Local and network data collection.
Skilled and multidisciplinary staff
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Specialist neonatal services have a sufficient, skilled and competent multidisciplinary workforce.
Quality measure
Structure
(a) Evidence of local arrangements to ensure specialist neonatal staff are compliant with competency levels as described by the Department of Health toolkit (2009).
(b) Evidence of local arrangements to provide a multidisciplinary service, trained and competent in the care of neonates, that has access to:
- specialist neonatal or paediatric dietitians
- specialist neonatal occupational therapists
- specialist neonatal physiotherapists
- specialist neonatal speech and language therapists
- specialist neonatal pharmacists.
Process
Proportion of completed specialist neonatal care shifts with the correct nursing and medical staffing levels as specified in the Department of Health toolkit (2009).
Numerator: the number of shifts with the correct nursing and medical staffing levels as specified in the Department of Health toolkit (2009).
Denominator: the number of completed specialist neonatal care shifts.
Description of what the quality statement means for each audience
Service providers ensure specialist neonatal services are staffed in accordance with the Department of Health toolkit (2009), and that training and competencies are regularly reviewed.
Healthcare professionals ensure they are skilled and competent for their roles and responsibilities by accessing appropriate training.
Commissioners ensure that specialist neonatal services assess and monitor the staffing levels, composition and competency of their workforce. In addition, they ensure that appropriate education programmes are commissioned.
Parents of babies receiving specialist neonatal care can expect care to be given by an appropriate number of fully trained healthcare professionals.
Definitions
Definition of a skilled and competent workforce can be found in Department of Health toolkit (2009) Principle 2.
The process measure 'proportion of completed shifts with the correct nursing and medical staffing levels' was considered by the Topic Expert Group (TEG) as an appropriate measure of staffing. It is noted that this is not a mandatory data collection requirement and that collection of this data is at the discretion of local units.
Data source
Structure
Local data collection.
Process
Local data collection.
Neonatal transfer services
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Neonatal transfer services provide babies with safe and efficient transfers to and from specialist neonatal care.
Quality measure
Structure
Evidence of network arrangements to provide a 24-hour, 7 days a week neonatal transport service with a single telephone contact.
Process
(a) Proportion of transfer teams responding to time-critical emergencies that depart from the transport base within 1 hour from the start of the referring call.
Numerator: the number of transfer teams departing from the transport base within 1 hour from the start of the referring call.
Denominator: the number of emergency transfer requests deemed time-critical.
(b) Proportion of newborn babies who receive specialist neonatal care who have an admission temperature of less than 36°C.
Numerator: the number of newborn babies with an admission temperature of less than 36°C.
Denominator: the number of newborn babies receiving specialist neonatal care.
Description of what the quality statement means for each audience
Service providers ensure a safe and efficient service for babies transferred to and from specialist neonatal care.
Healthcare professionals ensure babies receive a safe and efficient transfer to and from specialist neonatal care.
Commissioners and networks ensure transfer services are contracted and monitored to provide appropriate levels of service provision.
Parents of babies who need to be transferred to or from specialist neonatal services can expect this to be done safely and efficiently.
Definitions
The Department of Health toolkit (2009) states 'a transfer service is concerned with organising and implementing the transfer of babies and/or mothers from within a defined geographical area (network). It encompasses both users and providers, and transfers may be ex-utero or in-utero.'
Further description of a high quality transfer service can be found in Principle 4 of the Department of Health toolkit (2009).
Data source
Structure
Network data collection.
Process
(a) and (b): Network data collection.
Encouraging parental involvement in care
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Parents of babies receiving specialist neonatal care are encouraged and supported to be involved in planning and providing care for their baby, and regular communication with clinical staff occurs throughout the care pathway.
Quality measure
Structure
(a) Evidence of local arrangements to involve parents in decision-making processes.
(b) Evidence of local audit demonstrating active involvement of parents in providing care for their baby.
(c) Evidence of regular surveys on parent experience.
(d) Evidence of local arrangements to provide bereavement services.
(e) Evidence of local arrangements to provide palliative care.
Process
Parents' experience is monitored through satisfaction surveys and the evidence used to inform learning and change for improvement.
Description of what the quality statement means for each audience
Service providers ensure a policy is in place to maintain accurate records of communication with parents of babies receiving specialist neonatal care and that parents are involved in planning and providing care. Ensure plans are in place to seek regular parental views and experience.
Healthcare professionals communicate regularly with parents of babies receiving specialist neonatal care and ensure parents are involved in decision-making and their baby's care.
Commissioners ensure services use parental feedback on involvement in decision-making and planning and provision of care to inform service improvement of specialist neonatal care.
Parents of babies receiving specialist neonatal care can expect to be encouraged and supported to be actively involved in planning and providing care, joint decision-making and to be in regular contact with their healthcare team.
Definitions
Support provided will depend on the parents needs and may include physical, psychological or social support.
Data source
Structure
(a), (b), (d) and (e): Local data collection.
(c): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme denominator survey Question 8: In the last 12 months has the unit carried out a parent satisfaction survey?
Process
A Picker Institute parent survey, developed in conjunction with Bliss, is in development and will contain questions specifically aimed at assessing parent involvement in care and decision-making.
Breastfeeding
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Mothers of babies receiving specialist neonatal care are supported to start and continue breastfeeding, including being supported to express milk.
Quality measure
Structure
Evidence of a written local policy on breastfeeding and expressing milk for babies receiving specialist neonatal care.
Outcomes
(a) Proportion of babies born at less than 33 weeks of gestation who receive specialist neonatal care who are breastfed when discharged from hospital.
Numerator: the number of babies breastfed when discharged from hospital.
Denominator: the number of babies born at less than 33 weeks of gestation receiving specialist neonatal care and discharged from hospital.
(b) Proportion of babies born at less than 33 weeks of gestation who remain in hospital and still receive their mother's breast milk at 6 weeks.
Numerator: the number of babies receiving their mother's breast milk at 6 weeks.
Denominator: the number of babies born at less than 33 weeks of gestation, receiving specialist neonatal care and remaining in hospital at 6 weeks.
Description of what the quality statement means for each audience
Service providers ensure implementation of a local policy on breastfeeding and expressing milk for babies in specialist neonatal care.
Healthcare professionals ensure all mothers of babies receiving specialist neonatal care are supported to start and continue breastfeeding, including support to express milk.
Commissioners ensure services audit their compliance against agreed standards on supporting mothers to start and continue breastfeeding, including support to express milk.
Mothers of babies receiving specialist neonatal care can expect to be offered support to start and continue to breastfeed, including support to express milk.
Data source
Structure
Local data collection.
Outcomes
(a): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme produce figures on feeding status at discharge for babies born at less than 33 weeks of gestation.
(b): Local data collection.
Coordinated transition to community care
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Babies receiving specialist neonatal care have their health and social care plans coordinated to help ensure a safe and effective transition from hospital to community care.
Quality measure
Structure
(a) Evidence of provision of a neonatal outreach service.
(b) Evidence of multiagency discharge planning with input from community neonatal outreach services.
Process
Proportion of babies discharged from specialist neonatal care who receive an outreach service follow-up.
Numerator: the number of babies receiving outreach service follow-up.
Denominator: the number of babies discharged from specialist neonatal care requiring an outreach service follow-up.
Description of what the quality statement means for each audience
Service providers ensure that agreements are in place for coordinating the care plans of babies receiving specialist neonatal care between relevant agencies.
Health and social care professionals ensure the care plans of babies receiving specialist neonatal care are coordinated with all relevant agencies.
Commissioners and networks ensure services are commissioned according to agreed levels of care across the specialist neonatal care pathway to enable safe and effective transition from hospital to community care.
Parents of babies discharged from specialist neonatal care can expect to receive support from health or social care professionals working in the community if their baby requires it. They can also expect that their baby's care plan will be coordinated between relevant teams to help ensure a safe and effective transition from hospital to home.
Data source
Structure
(a) and (b): Local and network data collection.
Process
Local and network data collection.
Data, audit and research
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Providers of specialist neonatal services maintain accurate and complete data, and actively participate in national clinical audits and applicable research programmes.
Quality measure
Structure
(a) Evidence of a documented data validation process to ensure data completeness and accuracy.
(b) Evidence of participation in national clinical audits and benchmarking.
(c) Evidence of participation in applicable research studies.
Process
(a) Complete and accurate data collected for the National Neonatal Audit Programme.
(b) Complete and accurate data collected for the British Association of Perinatal Medicine (BAPM) dataset.
(c) Proportion of babies receiving specialist neonatal care whose parents are invited to participate in applicable research studies.
Numerator: the number of babies whose parents are invited to participate in applicable research studies.
Denominator: the number of babies receiving specialist neonatal care.
Description of what the quality statement means for each audience
Service providers ensure accuracy and completeness of specialist neonatal data collection systems and participate in national clinical audits and applicable research programmes.
Healthcare professionals ensure accurate record keeping and data collection.
Commissioners ensure service providers participate in agreed national clinical audits and applicable research programmes.
Parents of babies receiving specialist neonatal care can expect complete and accurate information to be kept about their baby's care and for it to be used to improve care. They can also expect to be invited to participate in applicable research programmes.
Data source
Structure
(a): Local and network data collection.
(b): Participation in the Royal College of Paediatrics and Child Health National Neonatal Audit Programme.
Process
(a): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme provides quarterly data completeness and accuracy reports to participating sites.
(b): Data completeness and accuracy figures of BAPM dataset submissions.
(c): Local and network data collection.
Health outcomes
This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.
Quality statement
Babies receiving specialist neonatal care have their health outcomes monitored.
Quality measure
Structure
Evidence of processes to enable collection of health outcome data within the network for babies who receive specialist neonatal care.
Process
(a) Proportion of babies born at less than 30 weeks of gestation who received specialist neonatal care who have a 2-year outcome form completed.
Numerator: the number of babies with a completed 2-year outcome form.
Denominator: the number of babies born at less than 30 weeks of gestation receiving specialist neonatal care.
(b) Proportion of babies born at 30 weeks of gestation or more who received specialist neonatal care who have a 2-year outcome form completed.
Numerator: the number of babies with a completed 2-year outcome form.
Denominator: the number of babies born at 30 weeks of gestation or more receiving specialist neonatal care.
(c) Proportion of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g who receive specialist neonatal care and undergo retinopathy screening prior to discharge from hospital.
Numerator: the number of babies undergoing retinopathy screening prior to discharge from hospital.
Denominator: the number of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g, receiving specialist neonatal care and discharged from hospital.
(d) Proportion of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g who receive specialist neonatal care who require laser surgery.
Numerator: the number of babies requiring laser surgery.
Denominator: the number of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g receiving specialist neonatal care.
e) Proportion of babies who received specialist neonatal care who have had a culture-positive infection of blood or cerebrospinal fluid prior to discharge from hospital.
Numerator: the number of babies who have had a culture-positive infection of blood or cerebrospinal fluid prior to discharge from hospital.
Denominator: the number of babies receiving specialist neonatal care.
f) Proportion of babies who have had neonatal encephalopathy.
Numerator and denominator under development for the National Neonatal Audit Programme.
Outcomes
(a) Proportion of babies born at less than 30 weeks of gestation who receive specialist neonatal care who have no functional impairment at 2 years when corrected for gestational age.
Numerator: the number of babies with no functional impairment at 2 years when corrected for gestational age.
Denominator: the number of babies born at less than 30 weeks of gestation receiving specialist neonatal care.
(b) Proportion of babies born at 30 weeks of gestation or more who receive specialist neonatal care who have no functional impairment at 2 years when corrected for gestational age.
Numerator: the number of babies with no functional impairment at 2 years when corrected for gestational age.
Denominator: the number of babies born at 30 weeks of gestation or more receiving specialist neonatal care.
(c) 2-year survival rates within and compared with other networks.
Description of what the quality statement means for each audience
Service providers ensure the health outcomes of all babies receiving specialist neonatal care are monitored.
Healthcare professionals ensure accurate and complete baseline data collection through pregnancy, childbirth and the perinatal period.
Commissioners and networks ensure specialist neonatal care health outcomes are monitored and used to inform service improvement.
Parents of babies receiving specialist neonatal care can expect their baby's health will continue to be assessed after discharge from hospital.
Data source
Structure
The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether health outcomes are collected.
Process
(a) and (b): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether 2-year outcomes are collected.
(c): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on retinopathy screening prior to discharge from hospital for babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g.
(d): Local and network data collection.
(e): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme will collect data on babies who have had a culture-positive infection of blood or cerebrospinal fluid prior to discharge.
(f): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme will collect data on neonatal encephalopathy.
Outcomes
(a), (b) and (c): Network data collection.
For further information see the Royal College of Paediatrics and Child Health National Neonatal Audit Programme.
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
NICE has also written a neonatal jaundice parent information factsheet.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
25 January 2013 Minor maintenance updates
21 October 2011 Minor maintenance updates
Supporting information
Glossary
In this pathway, the term 'diet' refers to the habitual eating patterns of individuals and groups of people who are not slimming or eating to manage or treat a medical condition.
Life-threatening or potential life-threatening situation.
Under UK law, follow-on formula may provide the liquid component of a progressively varied diet for healthy infants aged over 6 months.
There is no standard definition. However it is widely accepted that 'healthy eating' means following a diet which is low in fat (particularly saturated fat), sugar and salt, and high in fruit, vegetables and fibre-rich starchy foods. More details are available from NHS Choices.
Under UK law, infant formula is the term used to describe a food intended to satisfy, by itself, the nutritional needs of infants during the first months of life. The Department of Health advises that infant formula may be used on its own for the first 6 months.
Continue to monitor and assess.
An elevation of the serum bilirubin to a level requiring treatment.
Potentially serious situation, which needs appropriate action.
Jaundice detected by visual inspection.
Weaning or 'complementary feeding' is the transition from an exclusively milk-based diet to a diet based on solid foods.
Care of women and their babies
Care of women and their babies
Risk factors and information on neonatal jaundice
Risk factors and information on neonatal jaundice
Risk factors and information on neonatal jaundice
Risk factors for neonatal jaundice
Babies are more likely to develop significant hyperbilirubinaemia if they have any of the following factors:
- gestational age under 38 weeks
- a previous sibling with neonatal jaundice requiring phototherapy
- mother's intention to breastfeed exclusively
- visible jaundice in the first 24 hours.
Check for these factors soon after birth and ensure these babies receive an additional visual inspection by a healthcare professional during the first 48 hours of life.
Inspection for neonatal jaundice
Examine the baby for jaundice at every opportunity, especially in the first 72 hours.
When looking for jaundice (visual inspection):
- check the naked baby in bright and preferably natural light
- examination of the sclerae, gums and blanched skin is useful across all skin tones.
For information about treating a baby with suspected or obvious jaundice, including emergency treatment, see the neonatal jaundice pathway.
Information and support for parents and carers
Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. This information should be provided through verbal discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include:
- factors that influence the development of significant hyperbilirubinaemia
- how to check the baby for jaundice
- what to do if they suspect jaundice
- the importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice
- the importance of checking the baby's nappies for dark urine or pale chalky stools
- the fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless
- reassurance that breastfeeding can usually continue.
Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced.
NICE has written information for parents and the public explaining the guidance on neonatal jaundice and a neonatal jaundice parent information factsheet.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeEvery contact
Every contact
Every contact
Woman's well-being and care
Ask about:
- physical and emotional health and well-being
- coping strategies and support
- experience of common health problems (see common health problems in women in this pathway)
Discuss vaginal loss, healing of perineum, headache symptoms.
No need to take temperature unless signs and symptoms of infection.
Encourage the woman and family members to report concerns.
Look out for signs and symptoms of maternal mental health problems.
Update postnatal care plan.
Give information on:
- promoting health (see the smoking pathway and the physical activity pathway)
- recognising common health problems in women
- managing fatigue with diet, exercise and planning activities.
Baby's well-being and feeding
Healthy babies should have normal colour for their ethnicity, maintain a stable body temperature, and pass urine and stools at regular intervals. They initiate feeds, suck well on the breast (or bottle) and settle between feeds. They are not excessively irritable, tense, sleepy or floppy.
The vital signs of a healthy baby should fall within the following ranges:
- respiratory rate normally 30–60 breaths per minute
- heart rate normally 100–160 beats per minute in a newborn
- temperature in a normal room environment of around 37°C (if measured).
Ask about:
- the baby's health
- breastfeeding; document any support needed in postnatal care plan.
Encourage the woman to contact you if her baby is jaundiced, the jaundice is getting worse or her baby is passing pale stools. For more information see the neonatal jaundice pathway.
Provide advice and support for breastfeeding women.
Advise the woman of signs and symptoms of mastitis and encourage her to report any concerns to you urgently.
Give information on:
- promoting the baby's health
- recognising problems
- the baby's social capabilities
- local support.
Assess emotional attachment, see the first week in this pathway.
Provide contact details of healthcare professional or emergency service.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeFirst 24 hours
First 24 hours
First 24 hours
Woman's well-being and care
Take the woman's blood pressure and document the result within the first 6 hours.
Document the first urine void within the first 6 hours.
Encourage gentle mobilisation.
Provide an opportunity to talk about the birth.
Be alert to life-threatening conditions in women.
Women who are obese should receive individualised care because of increased risk of thromboembolism. For further information see the venous thromboembolism pathway.
Give information on:
- signs and symptoms of life-threatening conditions in women
- the physiological process of recovery after birth.
Develop a postnatal care plan with the woman. This should include:
- relevant factors from the antenatal, intrapartum and immediate postnatal period
- plans for the postnatal period
- names, roles and contact details of the healthcare professionals involved.
A coordinating healthcare professional should be clearly identified for each woman.
If concerned about the woman's health, see life-threatening conditions in women and common health problems in women in this pathway.
Ensure woman has a copy of 'Birth to five' and the personal child health record.
Baby's well-being and feeding
Don't separate the woman and her baby within the first hour.
Encourage skin-to-skin contact.
Don't ask about feeding method before skin-to-skin contact.
Encourage initiation of breastfeeding within the first hour.
Offer skilled breastfeeding support – including advice on positioning, attachment, ways to prevent concerns.
Reassure women who leave hospital soon after birth about breastfeeding duration.
See breastfeeding in this pathway for advice on successful breastfeeding.
Offer all parents intramuscular vitamin K (1 mg IM) for their baby. If IM dose is declined, offer oral.
Give information on:
- bathing (cleansing agents, lotions and medicated wipes are not recommended)
- keeping the umbilical cord clean and dry
- the benefits of colostrum, breastfeeding and the timing of the first breastfeed. This information should be culturally appropriate
- formula feeding as required.
If concerned about the baby's health, see health problems in babies in this pathway.
NICE has written information for patients and the public explaining the guidance on postnatal care and on venous thromboembolism.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeFirst week
First week
First week
Woman's well-being and care
Read this alongside every contact in this pathway.
Ask about:
- constipation (within 3 days of giving birth).
Give information on:
- normal patterns of emotional changes (within 3 days of giving birth)
- perineal hygiene
- methods and timing of resumption of contraception.
If concerned about the woman's health, see life-threatening conditions in women and common health problems in women in this pathway.
Immunisation
Offer MMR to sero-negative women in hospital following birth and before discharge.
Advise women to avoid pregnancy for 1 month after MMR, but to continue breastfeeding.
For recommendations on non-sensitised Rh-D negative women, see the postnatal care guideline on the NICE website.
Baby's well-being and feeding
Assess breastfeeding
If an insufficiency of milk is perceived, reassure, review attachment and positioning and evaluate the baby's health. If the baby is not taking sufficient milk directly from the breast and supplementary feeds are necessary, expressed breast milk should be given by a cup or bottle. Other fluids are not recommended.
Don't give formula milk to breastfeeding babies unless medically indicated.
See breastfeeding in this pathway for advice on successful breastfeeding.
For information about breastfeeding concerns, see common breastfeeding concerns in this pathway.
Examining the baby
Encourage both parents to be present when examining the baby.
Carry out a full examination within 72 hours of birth (see newborn examination in this pathway) and explain its aims to parents.
Document this examination in the postnatal care plan and the personal child health record.
Share the results with the parents.
Offer a newborn blood spot test when the baby is 5–8 days old.
Emotional attachment
Promote parent–, mother–baby attachment.
Offer support and information to fathers.
Encourage social networks.
Offer group-based parenting programmes as required.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeNewborn examination
Newborn examination
Newborn examination
This full examination needs to be done within 72 hours and repeated at the end of the postnatal period.
Review the health history of the family, woman and baby and address any parental concerns.
Carry out a physical examination of the baby. This should include checking the:
- appearance, including colour, breathing, behaviour, activity and posture
- head (including fontanelles), face, nose, mouth including palate, ears, neck and general symmetry of head and facial features. Note head circumference
- eyes; check opacities and 'red reflex'
- neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry
- heart; check position, rate, rhythm and sounds, murmurs and femoral pulse volume
- lungs; check effort, rate and sounds
- abdomen; check shape and palpate to identify any organomegaly; also check umbilical cord
- genitalia and anus; check completeness and patency and undescended testes in males
- spine; palpate bony structures and check integrity of skin
- skin; note colour and texture as well as birthmarks or rashes
- central nervous system; check tone, behaviour, movements and posture, and elicit reflexes only if concerned
- hips; check symmetry of limbs and skin folds; perform Barlow and Ortolani's manoeuvres
- cry; note sound
- weight; note.
Carry out appropriate recommendations made by the NHS National Screening Committee.
As a minimum, ensure babies are weighed at birth and in the first week as part of an overall assessment of feeding. Thereafter, healthy babies should usually be weighed at 8 weeks at the time of routine immunisation, and then at subsequent routine immunisations. If there is concern, weigh more often, but no more than once a month up to 6 months of ageThis advice has been amended to be consistent with the UK World Health Organization child growth charts published in 2009. The original advice was: As a minimum, ensure babies are weighed (naked) at birth and at 5 and 10 days, as part of an overall assessment of feeding. Thereafter, healthy babies should be weighed (naked) no more than fortnightly and then at 2 months..
Ensure infants are weighed using digital scales which are maintained and calibrated annually, in line with medical devices standards (spring scales are inaccurate and should not be used).
If there are suspected or obvious signs of jaundice, refer to the neonatal jaundice pathway for more information.
First 2–8 weeks
First 2–8 weeks
First 2–8 weeks
Woman's well-being and care
Read these pages alongside every contact in this pathway.
If concerned about the woman's health, see common health problems in women and life-threatening conditions in women in this pathway.
Ask about:
- resumption of sexual intercourse (within 2–6 weeks)
- resolution of baby blues (within 10–14 days).
Give information on:
- common health problems (see common health problems in women in this pathway)
- contraception, including contact details for expert advice
- local peer, statutory and voluntary groups (within 2–8 weeks).
At the end of the postnatal period, the coordinating healthcare professional should review the woman's physical, emotional and social well-being. Screening and medical history should also be taken into account.
Baby's well-being and feeding
Assess and educate the family regarding safety issues.
Promote the correct use of basic safety equipment such as infant seats and smoke alarms.
Be alert to signs of domestic abuse or child abuse. If concerned follow guidance from the Department of Health National Service Framework for Children, Young People and Maternity Services and Responding to domestic abuse: a handbook for health professionals and local child protection policy, respectively.
Offer routine immunisations.
At 6–8 weeks repeat the newborn examination in this pathway and assess social smiling and visual fixing and following.
Complete a hearing screen within 4–5 weeks.
Recommendations made by the NHS National Screening Committee should be carried out.
Sudden infant death syndrome
Advise parents of Department of Health guidance: 'The safest place for your baby to sleep is in a cot in your room for the first six months.'
Advise parents never to sleep on a sofa or armchair with their baby.
If parents choose to share a bed with their baby, advise of increased risk of sudden infant death if either parent: is a smoker; has recently drunk any alcohol; has taken medication or drugs that make them sleep more heavily; or is very tired.
Use of a pacifier (dummy) should not be stopped suddenly.
If concerned about the baby's health, see health problems in babies in this pathway.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeHealth problems in women and babies
View the 'Health problems in women and babies in postnatal care' pathInfant feeding and maternal nutrition
View the 'Infant feeding and maternal nutrition in postnatal care' pathA supportive environment
A supportive environment
A supportive environment
All healthcare providers should:
- have local protocols about communication and the transfer of care between clinical sectors and healthcare professionals
- ensure the Baby Friendly Initiative (or another similar externally evaluated breastfeeding programme) is implemented
- have a written breastfeeding policy that is communicated and implemented
- ensure breastfeeding support is available in all care locations.
Hospitals should ensure:
- round the clock rooming in
- privacy
- adequate rest
- ready access to food and drink.
How long a woman stays in hospital after birth should be negotiated; consider the health and well-being of the woman and her baby and the level of support available following discharge.
Commercial packs that contain formula milk or advertisements for formula should not be distributed.
Recommendations for public, community, voluntary and private sector organisations
Commissioners and managers should work with local partners to ensure mothers can feed their babies in public areas without fear of interruption or criticism.
The Healthy Start scheme
Promote the Healthy Start scheme. Ensure an adequate supply of application forms is available and that uptake of benefits is regularly audited.
Community pharmacists should ensure the Healthy Start maternal vitamin supplements are available for purchase by women who are not eligible to receive them free of charge.
Implementation tools
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Competencies and training
Competencies and training
Competencies
All healthcare professionals caring for women and their babies should meet the relevant competencies developed by Skills for Health.
If relevant, you should also have demonstrated competency and ongoing experience in:
- maternal and newborn physical examinations
- supporting breastfeeding women
- recognising the signs and symptoms of maternal mental health problems
- recognising risks, signs and symptoms of domestic and child abuse and knowing who to contact for advice.
Topics for training and continuing professional development
The nutritional needs of women and the importance of a balanced diet before, during and after pregnancy (including the need for suitable folic acid supplements).
The importance of vitamin D supplements for all pregnant and breastfeeding women.
Breastfeeding management, using the Baby Friendly Initiative training as a minimum standard.
For breastfeeding peer supporters: how to provide breastfeeding peer support (a recognised, externally accredited training course).
For link workers who speak the mother's first language: how to provide information and support on breastfeeding, use of infant formula, weaning and healthy eating.
Training on weighing and measuring infants. This should include: how to use equipment, how to document and interpret the data, and how to help parents and carers understand the results and implications.
Support staff need training to weigh infants and to record the data accurately in the child health record held by the parents.
Local breastfeeding policy
Local breastfeeding policy
Local breastfeeding policy
Encouraging breastfeeding
Adopt a multifaceted approach or a coordinated programme of interventions across different settings to increase breastfeeding rates. It should include:
- activities to raise awareness of the benefits of – and how to overcome the barriers to – breastfeeding
- training for health professionals
- breastfeeding peer-support programmes
- joint working between health professionals and peer supporters
- education and information for pregnant women on how to breastfeed, followed by proactive support during the postnatal period (the support may be provided by a volunteer).
Implement a structured programme that encourages breastfeeding, using the Baby Friendly Initiative as a minimum standard. The programme should be subject to external evaluation.
Ensure there is a written, audited and well-publicised breastfeeding policy that includes training for staff and support for those staff who may be breastfeeding. Identify a health professional responsible for implementing this policy.
Ensure health professionals who provide information and advice to breastfeeding mothers have the required knowledge and skills.
Ensure support workers receive training in breastfeeding management from someone with the relevant skills and experience before they start working with breastfeeding mothers.
Ensure all those who work in maternity and children's services, including receptionists, volunteers and ancillary staff, are made fully aware of the importance of breastfeeding and help to promote a supportive environment.
Avoid promoting or advertising infant or follow-on formula.
Do not display, distribute or use product samples, leaflets, posters, charts, educational or other materials and equipment produced or donated by infant formula, bottle and teat manufacturers.
Peer support and link workers
Provide local, easily accessible breastfeeding peer support programmes and ensure peer supporters are part of a multidisciplinary team.
Ensure peer supporters:
- attend a recognised, externally accredited training course in breastfeeding peer support
- contact new mothers directly within 48 hours of their transfer home (or within 48 hours of a home birth)
- offer mothers ongoing support according to their individual needs. This could be delivered face-to-face, via telephone or through local groups
- can consult a health professional and are provided with ongoing support
- gain appropriate child protection clearance.
NHS trusts should train link workers who speak the mother's first language to provide information and support on breastfeeding, use of infant formula, weaning and healthy eating.
Where link workers are not available, ensure women whose first language is not English have access to interpreting services and information in a format and language they can understand.
NHS trusts should encourage women from minority ethnic communities whose first language is not English to train as breastfeeding peer supporters.
Prescribing medication
Ensure health professionals and pharmacists who prescribe or dispense drugs to a breastfeeding mother consult supplementary sources (for example, the Drugs and Lactation Database [LactMed] ) or seek guidance from the UK Drugs in Lactation Advisory Service.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
- Health problems in women and babies in postnatal care
- Infant feeding and maternal nutrition in postnatal care
Pathway created: May 2011 Last updated: January 2013
Copyright © 2013 National Institute for Health and Care Excellence. All Rights Reserved.