A precipitate delivery may cause facial congestion that can be misdiagnosed as cyanosis. An instrumental delivery may result in the newborn suffering a degree of head trauma, such as bruising, which may require analgesia and can increase the risk of hyperbilirubinaemia (see Table 1.2 and Chapter 3).
Meconium stained liquor (MSL) can be problematic for a minority of newborns and therefore must be noted from the delivery summary. The presence of MSL is associated with an increased mortality and morbidity, accounting for 2% of perinatal deaths (NICE 2017). It is relatively common with an occurrence of 15–20% in term pregnancies (NICE 2017). Although meconium aspiration syndrome is relatively rare, some of these infants may seem well at delivery but rapidly develop signs of respiratory compromise as a result of aspiration. The National Institute for Health and Care Excellence (NICE) (2017) advocates close observation of the newborn with MSL present at delivery in the immediate postnatal period.
Early onset neonatal sepsis
Newborn examiners must be continuously on the alert for possible risk factors for early onset neonatal sepsis. Early onset sepsis in the newborn is a significant contributor to perinatal mortality. One of the most common bacterial isolates is group B haemolytic streptococcus (GBS), which carries a mortality of 6% in term infants and 18% in preterm infants (NICE 2017). Maternal infection during the antenatal period must be actively treated with antibiotic therapy. Treatment with antibiotics for the newborn may also be required but is risk dependent or if the newborn is symptomatic (NICE 2012; RCOG 2017). Ohlsson and Shah (2009) inferred that intrapartum antibiotic therapy does reduce the risk of early onset GBS in the newborn.
In the case of pre‐labour prolonged rupture of membranes (PROM), the length of time must be noted (NICE 2012). The risk of early onset GBS infection in the newborn is greater in women with PROM (NICE 2012; RCOG 2017). In the absence of any other symptoms, true maternal pyrexia in labour must never be ignored. In addition, there was no strong evidence to recommend antibiotic prophylaxis for newborns of women with PROM in labour (NICE 2012).
Conversely, the symptomatic newborn must commence antibiotic therapy and admission to the neonatal unit for further diagnostics. Every newborn must be treated on an individual basis, depending on the risk factors presenting. Multiple risk factors will necessitate newborn screening for infection and the commencement of antibiotic prophylaxis until blood culture results become available. Local policy on the prevention and detection of early onset sepsis in the newborn must reflect the red flag and non‐red flag risk indicators as detailed in the NICE guidance for neonatal infection early onset (NICE 2012) available at https://www.nice.org.uk/guidance/cg149. The NICE guidance advocates the avoidance of routine antibiotic therapy.
It is estimated that 90% of newborns with early onset sepsis will be symptomatic within 12 hours of birth (NICE 2017). Therefore, all newborns with risk factors for early onset infection must receive close observation as indicated on the local neonatal early warning score (NEWS) chart. A framework for the use of the neonatal early warning trigger and track (NEWTT) chart can be found on the British Association of Perinatal Medicine (BAPM) website: https://www.bapm.org/resources/38‐newborn‐early‐warning‐trigger‐track‐newtt‐a‐framework‐for‐practice‐2015.
The NIPE examiner must ensure that the observations are documented on the NEWS chart and reviewed within the context of the examination and assessment of the overall health of the newborn.
Infant of the diabetic mother
The newborn of the diabetic mother, irrespective of diabetes type, will require blood glucose monitoring. The newborn examiner must review the blood glucose results prior to conducting the examination. Local policy will dictate the monitoring intervals for such newborns. Suboptimal results will require more active management of hypoglycaemia that may necessitate admission to the neonatal unit (BAPM 2017). The BAPM guidance for the identification and management of neonatal hypoglycaemia can be found at https://www.bapm.org/resources/40‐identification‐and‐management‐of‐neonatal‐hypoglycaemia‐in‐the‐full‐term‐infant‐2017.
The NHS Antenatal Screening Programme
Antenatal serology results
The NHS Antenatal Screening Programme components (Table 1.3) aim to help the NIPE examiner navigate investigations and results and signpost the relevant information within the maternal medical records. Familiarisation with the key components of the programme will enhance this process.
The maternal prenatal serology results must be reviewed, particularly the rhesus status. A maternal rhesus negative status or the presence of antibodies should alert the NIPE examiner to the possibility of rhesus incompatibility and the risk of early onset pathological hyperbilirubinaemia with the first 24 hours of life. A sibling of the newborn with neonatal jaundice requiring phototherapy carries a significant risk (NICE 2016). Further information on neonatal jaundice management guidelines can be found on the NICE website: https://www.nice.org.uk/guidance/cg98. Surveillance of the newborn should be increased, particularly in the case of an early discharge to the community.
The maternal human immunodeficiency virus (HIV), hepatitis B and hepatitis C status should be reviewed in all cases. Antiviral therapy will be required for the newborn of an HIV positive mother (PHE 2016; 2019b) in accordance with the national British HIV guidelines (British HIV Association 2019) available from https://www.bhiva.org/file/5bfd30be95deb/BHIVA‐guidelines‐for‐the‐management‐of‐HIV‐in‐pregnancy.pdf.
The newborn of a hepatitis B positive mother will require vaccination with or without immunoglobulin within 4 hours of birth and follow the hep vaccine schedule for the first year of life (PHE 2016; 2019b) in accordance with the PHE Green Book recommendations (PHE 2014) available from https://www.gov.uk/government/collections/immunisation‐against‐infectious‐disease‐the‐green‐book#the‐green‐book.