- Organization of perinatal services
- Neonatal transport
- Special considerations
Introduction
The majority of babies are born at or near term and are clinically well after birth. Specialist neonatal care is often provided in specific geographical locations where a critical mass of expertise can be placed. Ideally, pregnant mothers should deliver at a place that can provide the necessary care for their baby. For a variety of reasons, a number of babies will require emergency transport to a hospital that is capable of providing ongoing management. The care and transport of sick and premature infants requires specific skills, knowledge and resources.
Organization of Perinatal Services
Highly regionalized models for the delivery of perinatal services have developed over time. Perinatal services may provide:
- standard antenatal care
- antenatal care with maternal fetal medicine (MFM) services
- planned management of birth
- care and assessment of well newborn infants
- neonatal special care
- neonatal intensive care including care of extremely preterm and extremely low birthweight (ELBW) infants
- neonatal care of specific surgical and cardiac conditions
- specialized transport services for infants requiring care at another facility
- follow-up and ongoing care after discharge from the neonatal service.
The goals of these perinatal services are to improve outcomes with high critical mass and provide cost-effective perinatal care.
Levels of Perinatal Care
Neonatal intensive care is a coordinated effort by health care providers in a defined geographical region to intervene in the reproductive process so as to make available to every neonate a level of medical care commensurate with the perceived risk of neonatal death or serious morbidity. The integration of neonatal and obstetric services into a perinatal programme offers the best opportunity for prevention and treatment.
A neonatal intensive care unit (NICU) should provide care for all babies born in a district or region, and babies requiring intensive care are referred to the intensive care nursery. Facilities for neonatal surgery and cardiology should be available in NICUs. When infants no longer require intensive care services they should be transferred back to the most appropriate service closest to their home.
Different countries have different ways of defining the levels of care (see Tables 25.1 and 25.2).
Table 25.1 Levels of neonatal care in the UK
| Level 1 hospitals | Provide special care but do not aim to provide any continuing high-dependency or intensive care. This term includes units with or without resident medical staff. The requirement is for one nurse to every four babies |
| Level 2 hospitals | Provide high-dependency care and some short-term intensive care as agreed within the network. This requires one trained nurse to two babies |
| Level 3 hospitals | Provide the whole range of medical neonatal care but not necessarily all specialist services such as neonatal surgery. This requires one-to-one specialist nursing per cot |
Table 25.2 Levels of neonatal care in Australia and New Zealand
| Level 1 hospitals | (50–400 deliveries per annum). These provide services for uncomplicated maternity and newborn patients >36 weeks’ gestation. The mature infant nursery provides basic life supports and receives back transfer from level 2 hospitals |
| Level 2 hospitals | (400–2000 deliveries per annum). These provide services for low- and medium-risk pregnancies and for babies >32 weeks’ gestation. The special care nursery (SCN) is staffed by neonatal nurses and a paediatric registrar and consultant, and can provide stabilization of preterm and sick infants prior to neonatal retrieval |
| Level 3 hospitals | (usually >3000 births and >10,000 births in catchment area). These provide services for low-, medium- and high-risk obstetrics, have a maternal fetal medicine unit and a full range of ventilation options. The staff include neonatal nurses, neonatal registrars and a consultant, and there is access to a full range of paediatric subspecialties. These units may be located in obstetric hospitals, in general hospitals or in children’s hospitals. There is a nurse:patient ratio of 1:2, or 1:1 for unstable infants |
| Level 4 hospitals | This is a term that is sometimes used to describe services provided to neonates requiring paediatric subspecialty care (e.g. those with complex metabolic and/or cardiac conditions, and surgical cases) |
Tertiary perinatal services have a strong focus on quality improvement, evidence-based practice, risk reduction, clinical audit, ethics and research. The types of patients that should be cared for in NICUs are listed in Box 25.1 and the types of problems that can be admitted to a high-dependency unit are listed in Box 25.2. Level 1 special care is provided for all other babies who could not reasonably be expected to be looked after at home by their mother. Normal care is care given in a postnatal ward, usually by the mother under the supervision of a midwife or doctor but requiring minimal medical or nursing advice.
- Any baby receiving any respiratory support via a tracheal tube and in the first 24 h after withdrawal of such support
- Any baby receiving nasal continuous positive airway pressure (NCPAP) for any part of the day and expected to require NCPAP for a prolonged period.
- Babies requiring >50% oxygen
- Any baby below 1000 g current weight
- Babies requiring major emergency surgery, for the preoperative period and postoperatively for 24 h
- Babies requiring complex clinical procedures:
- Any other very unstable baby considered by the nurse in charge as needing one-to-one nursing
- Babies requiring short-term NCPAP and not fulfilling any of the criteria for intensive care
- Babies over 1000 g current weight and not fulfilling any of the criteria for intensive care
- Babies receiving total parenteral nutrition
- Babies having convulsions
- Babies receiving oxygen therapy and below 1500 g current weight
- Babies requiring treatment for neonatal abstinence syndrome
- Babies requiring specified procedures that do not fulfil any criteria for intensive care
- care of an intra-arterial catheter or chest drain
- partial exchange transfusion
- tracheostomy care until supervised by a parent
- care of an intra-arterial catheter or chest drain
- Babies requiring frequent stimulation for severe apnoea
All maternity units must provide normal care for babies. A district general hospital with a consultant obstetric unit should provide special care facilities, and approximately 6% of infants will require this type of care.
The Role of Neonatal Networks
Collaboration with a national neonatal network audits outcomes, provides benchmarking standards, develops clinical indicators, provides standardized guidelines and policies, allows consultation with the referring and receiving units, and facilitates research through critical mass.
Models of Care
Ideally mother and baby should be kept together as much as possible so that models of care for babies with special needs, such as neonatal abstinence syndrome (NAS), infants of diabetic mothers, marginal prematurity (35–36 weeks), intravenous antibiotics and jaundice requiring intensive phototherapy, should be predominantly provided by parents.
Neonatal services should be developed to oversee a continuum of care between the different levels, hospitals and community-based primary health facilities.
Neonatal Transport
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