Trust Guideline on Routine Oxygen Saturation Measurement on the New-born For Use in: By: For: Division responsible for document: Key words: Name and job title of document author: Name and job title of document author s Line Manager: Supported by: Assessed and approved by the: Maternity services, Delivery Suite, NICU, Postnatal ward Midwives and Maternity Care Assistants, NICU medical and nursing staff New-born babies Women and Children s Services Pulse Oximetry, Oxygen saturation, Congenital Heart Disease Dr Rahul Roy, Consultant Neonatologist David Booth, Chief of Women s and Children s Services Mrs Frances Bolger Head of Women s and Midwifery services Mrs Ann Walker Deputy Head of Midwifery Clinical Guidelines Assessment Panel (CGAP) If approved by committee or Governance Lead Chair s Action; tick here Date of approval: 25/09/2017 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this 25/09/2020 date but will be under review To be reviewed by: Dr Rahul Roy Reference and / or Trust Docs ID No: 10566 Version No: 2 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? Clinical Standards Group and Effectiveness Sub- Board No clinical changes None N/A This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 1 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the Newborn Quick reference guideline/s Oxygen Saturation Measurement: Care Pathway Flow Chart Check in foot at 4-12 hours > 95% Unable to obtain good trace < 95% Reassurance parents Document in baby notes No other actions needed Review by Neonatal staff (Specialist trainee/annp) Clinical examination including femoral pulses Repeat pre and post ductal > 95% AND Pre/post ductal difference < 2% Normal clinical examination 91-94% AND Baby well Pre/post ductal differences < 2% No clinical concerns < 90% OR Pre/post ductal difference > 2% Abnormal clinical examination Repeat in 1-2 hours Repeat < 95% or clinical concerns Admit in NNU until Diagnosis achieved or persistently normal observations Consider blood gas, echo, chest xray, nitrogen washout test etc. Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 2 of 7
Objective Role of routine pre discharge pulse oximetry screening in delivery suite and postnatal ward to improve early detection of critical cyanotic congenital heart disease (CCHD) in asymptomatic new-born babies. Rationale Cardiovascular malformations are the leading group of congenital malformations affecting 7-8/1000 newborn infants. They account for 6-10% of all infant mortality. Cardiovascular malformations also account for 20-40% of deaths attributable to all congenital malformations and most of these deaths occur in the first year of life. It is well recognized that antenatal screening and routine neonatal examination fail to detect up to 50% of congenital heart diseases (CHD). The signs of congenital heart disease are not always present in the first few hours of life, or even absent in the first few days after birth. This is because of the transition of circulation from foetal to normal child circulation, which involves pressure changes between the chambers of the heart and lungs. The earlier the examination is performed while this transition is taking place, the less accurate is routine clinical examination going to be. Some babies are identified as having heart murmurs on the routine baby check, which may represent these pressure changes in the heart chambers and lungs and hearing flow of blood through the heart or blood vessels. This can resolve without any intervention. Not all babies with a heart murmur have congenital heart disease. Interest has grown over recent years regarding the use of pulse oximetry in the early neonatal period to enhance the detection of such lesions. Research in over 250,000 infants has showed that pulse oximetry can help in picking up significant CHD. Research has shown that a combination of antenatal screening, routine examination of the newborn and measurement of oxygen saturation improves detection of critical CHD to over 90% and therefore maximise the detection rate of significant congenital heart conditions. Pulse oximetry has also been shown to be a very effective tool in picking up other potentially unwell infants with important non-cardiac conditions while they may appear well. Broad recommendations All babies born in hospital or admitted in postnatal ward after birth outside hospital (this could be for maternal or neonatal reasons) should have their oxygen saturations checked postnatally 4-12 hours after birth. This will be performed by midwives / midwifery care assistant (MCA). Practitioners undertaking the routine neonatal examination should ensure that oxygen saturations have been recorded in the baby notes. If oxygen saturations have not been performed, the midwife looking after the baby should be requested to do this. If the baby is more than 12 hours old then the test should still be undertaken as it still has value in screening for congenital heart disease. Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 3 of 7
Reasons for measuring oxygen saturation The ductus arteriosus, a connection between the aorta and the pulmonary artery which is commonly called the duct, allows blood to communicate between the left and the right sides of the heart while the baby is still in the uterus and the lungs are not working properly. Babies in the uterus get their oxygen via the placenta. This duct also allows mixing of blood between the left and right sides of the heart in a group of congenital heart conditions called duct-dependent congenital heart conditions. Closure of the duct, which is a natural phenomenon after birth, can result in sudden deterioration including collapse and even death in babies with duct-dependent congenital heart conditions. Oxygen saturation monitoring is a subtle way of potentially detecting such an abnormality in the face of a normal examination and could therefore facilitate early diagnosis of a significant cardiac condition, thereby reducing potential morbidity and mortality. Combining pulse oximetry screening with existing screening methods, antenatal screening and routine examination of the new-born, will improve detection of critical CHD cases to over 90%. Research studies have also showed that measuring oxygen saturation in the postnatal period can also help in the earlier diagnosis of other serious non-cardiac conditions e.g. infection, breathing difficulties etc before worsening of the baby s clinical condition. Measurement of oxygen saturation in new born babies The saturation probe is applied to the foot. For best readings tape must be applied to the foot to hold the probe in place (see appendix 1 for further details). It is necessary to wait until a stable good quality waveform is seen. A sustained, good signal reading of 95% is accepted as normal and constitutes no concerns. If oxygen saturation is < 95%, referral to the neonatology team is required for an assessment. Additionally, experience suggests that when a good trace cannot be detected by the method outlined above, the baby may be more unwell than is suspected by attending staff and such babies need review by a neonatal team member. These babies should be discussed with neonatal team who could triage the timing for review. Causes of low oxygen saturation in new born babies Undetected illness including potential infection, breathing difficulties, congenital heart disease and slow adaptation to ex-utero life are among the causes of low saturations. All these conditions merit neonatal review to diagnose, and if needed, to treat the underlying condition. Well new born babies with low oxygen saturation The babies who are otherwise well but found to have low oxygen saturation < 95% on pulse oximetry screening should be discussed with neonatal team who will triage the timing for review. Thorough examination by a member of the neonatal team is appropriate looking for any evidence of infection, breathing difficulty or congenital heart disease. If oxygen saturations are low in the foot (<95%), preductal (right hand) and postductal (feet) oxygen saturations should be checked by the neonatal team. Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 4 of 7
A difference of > 2% between the readings is considered abnormal and suggests right to left shunting. If there is no shunting i.e. preductal and postductal oxygen saturations difference 2% and the baby is otherwise well, with saturations between 91-94%, then admission to NICU may not be immediately needed. These babies should have repeat saturations performed 1-2 hours later by the midwife / midwifery care assistants. If a second screen is normal and no other concerns are present, then usual postnatal ward care can continue. If the second screen saturation results are abnormal and/or baby is symptomatic this should prompt urgent referral to neonatal team and admission to NICU for further assessments, investigations or treatment is indicated. On admission to Neonatal Unit post positive Pulse-Oximetry screen Baby symptomatic: quiet, less responsive, temperature instability (Hypothermia or Hyperthermia), tachyapnea with RR > 60/min, grunting respirations, nasal flaring, chest wall recessions, apnoea. Examination: Abnormal breath sounds, heart murmur, weak or absent femoral pulses and response to oxygen therapy Investigations: If respiratory and/or infective condition suspected from history & examination and saturations improve with oxygen and achieving normothermia then perform FBC, CRP, Blood culture and CXR as appropriate Echocardiogram should only be done at the discretion of the attending consultant after clinical assessment. Echocardiogram Indicated: Abnormal CVS examination, no respiratory signs, no response to oxygen and low saturation persists. Echocardiogram Unavailable Discuss with on call NICU consultant and Paediatric Cardiology registrar at GOSH regarding starting Prostin infusion and transfer to cardiac centre Clinical audit standards 1. All babies born in hospital and resident in the post-natal ward areas/delivery suite should have an oxygen saturation checked postnatal before discharge. 2. The reading should be taken 4-12 hours after birth. 3. The reading should be recorded in the baby s post-natal care record: as a single saturation reading recorded as a percentage with the date and time of the reading documented with the signature and designation of the health care professional performing the test Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 5 of 7
Summary of development and consultation process undertaken before registration and dissemination This guideline was drafted by Dr Rahul Roy on behalf of the Paediatric directorate. During its development it has been circulated and presented to the consultant neonatologist and midwifery staff for comments. It has been presented and discussed at the neonatal unit clinical guidelines meeting (attended by medical, nursing, ANNP of the neonatal unit and midwifery practice development staff). This guideline has been endorsed by the clinical Guidelines Assessment Panel Distribution list/ dissemination method Trust Intranet Midwifery and Neonatal Medicine Guidelines References 1. Ewer A et al (2011) Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. The Lancet; 378: 785-94. 2. Thangaratinam S et al (2007) Accuracy of pulse oximetry in screening for congenital heart disease in asymptomatic newborns: a systematic review. Arch Dis Child Fetal Neonatal Ed, 92: F176-180. 3. Thangaratinam S et al (2012) Pulse oximetry screening for critical congenital heart defects in asymptomatic newborn babies: a systematic review and metaanalysis. The Lancet, 379: 2459-64. 4. Granelli A et al (2009) Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39 821 newborns. British Medical Journal; 338: a3037. 5. Wren C, Richmond S, Donaldson L (2000) Temporal variability in the birth prevalence of cardiovascular malformations. Heart; 83: 414-419. 6. Wren C, Richmond S, Donaldson L (1999) Presentation of congenital heart disease in infancy: implications for routine examination. Arch Dis Child Fetal Neonatal Ed; 80: F49-53. 7. Ainsworth SB, Wyllie JP, Wren C (1999) Prevalence and clinical significance of cardiac murmurs in neonates. Arch Dis Child Fetal Neonatal Ed; 80: F43-45. 8. Singh A, Rasiah SV, Ewer AK (2014) The impact of routine predischarge pulse oximetry screening in a regional neonatal unit. Arch Dis Child Fetal Neonatal Ed;99:F297-F302. Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 6 of 7
Appendix 1: Checking Oxygen Saturation (SpO2) Measurement in a Baby 1) Explain to parents that you are going to check the baby s blood oxygen level and that it will not hurt the baby. 2) Place the flat sides of the probe at the lateral border on opposing sides of the foot (either foot is fine for this test). To get a good trace the probe faces must be opposite one another with red emitter light being on top (Fig 1). 3) Use Posey wrap to secure the probe - it is much less likely to pick up a safe and reliable trace if held in place by hand (Fig 2). Once connected turn on the power. Fig 1 Fig 2 4) Allow time for a stable reading to appear. This may take up to 30-60 seconds to settle. Always wait for a good trace as shown below (Fig 4). Fig 3: Poor Trace Action: Wait until you get a good trace Fig 4: Good trace Action: Pass; reassure parents saturation p Fig 5: Good trace with low saturation Action: Inform neonatal team 5) When a figure of 95% has been present for 20s (steady reading) with the baby breathing air, the baby has passed the test with a normal result! 6) If the saturations are persistently <95% or the trace is persistently poor (Fig 3) resulting in abnormal saturations (<95%) inform a neonatal team member (as per care pathway). 7) Clean probe with Deb wipes or similar detergent wipes. 8) Document oxygen saturation levels in the baby notes, date, time and sign. 9) Babies should not be discharged home without documented normal oxygen saturation levels Available via Trust Docs Version: 2 Trust Docs ID: 10566 Page 7 of 7