Visualise and measure

Midwives magazine: August 2010



Community midwife at University Hospitals of Leicester NHS Trust Yvonne Benjamin discusses how the updated NICE guideline on neonatal jaundice will impact on midwifery practice.

Jaundice is common in newborn babies – approximately four out of five preterm babies and three out of five full-term babies develop it in their first week of life (Patient UK, 2010).  Jaundice is recognised by the yellow colouration of the skin, mucous membranes, and sclera of the eyes. This is caused by high levels of bilirubin. In most healthy term babies, physiological jaundice resolves in ten to 12 days (Percival, 2003), however, some babies can develop very high bilirubin levels. Severe untreated jaundice can lead to kernicterus, a serious neurological condition causing cerebral palsy, hearing loss and visual and dental problems. It is estimated up to 12 babies develop this condition each year in the UK. The calculated lifetime cost of care for each child with kernicterus is £5.5m.

Recognition of neonatal jaundice, and the initiation of early treatment has been an area of clinical midwifery care subject to many uncertainties. Now, a new guideline from NICE aims to support midwives and others to standardise care and treatment of neonatal jaundice. Its key recommendations (see table) will ensure those babies at greater risk of jaundice are identified earlier, and effective and appropriate treatment is administered promptly, preventing kernicterus.

For midwives, the guideline’s most important recommendation is the recognition of neonatal jaundice during the first 72 hours of life. Routine examination of the newborn is carried out by midwives during the postnatal period (NICE, 2006). It is during the first postnatal home visit that midwives will now be able to carry out improved clinical assessment of neonatal jaundice. As documented in the guideline, assessment of neonatal jaundice by visualisation alone is no longer acceptable. The evidence supports additional diagnostic testing using a transcutaneous bilirubinometer (TBM), although this will not be appropriate in all cases (see recommendations). A TBM is a small hand-held device that is non-invasive and, when placed on the baby’s chest, will provide a numerical reading of the level of serum bilirubin circulating in the baby. NICE has developed a range of tools to help midwives in support of practice development.

Concerns regarding the training and use of diagnostic equipment have been acknowledged, however, this should be accepted as part of the ongoing development of midwives’ knowledge and skills. Diagnostic screening of neonatal jaundice will provide midwives with much needed refinement to practice. No longer will it be acceptable to state that a baby has ‘slight’, or a ‘hint’ or ‘touch’ of jaundice. With the well-designed tools available, jaundice will be recognised, documented and a clear pathway of care put into place.

Midwives’ ever-increasing workload is considered whenever any change in practice is proposed, especially as they are the key healthcare professionals for the implementation of this guideline. Additional screening of neonates with jaundice may mean midwives will have to undertake extra home postnatal visits during the first 72 hours of life. However, this presents midwives with an excellent opportunity to give women valuable support in other areas such as breastfeeding, parenting and clinical recovery from childbirth. The introduction of improved methods of identification, measurement, and treatment of neonates with jaundice will reduce the cost to parents and health professionals from unnecessary hospital readmission.

Midwives should also provide women with written and verbal information about neonatal jaundice during the antenatal period from 36 weeks onwards and soon after childbirth, ensuring that parents and carers of newborn babies share the responsibility of recognising this condition. 

References

NICE. (2006) Postnatal care: routine postnatal care of women and their babies. NICE: London. See: www.nice.org.uk/CG037 (accessed  1 July 2010).

NICE. (2010) Neonatal jaundice. NICE: London. See: www.nice.org.uk/CG98 (accessed 29 June 2010).

Patient UK. (2010) Neonatal jaundice. See: www.patient.co.uk/showdoc/40000454/ (accessed 29 June 2010).

Percival P. (2003) Jaundice and infection: In: Fraser DM, Cooper MA. (Eds.). Myles textbook for midwives (14th edition). Churchill Livingstone: London: 863.


Implementation tools

Tools developed to help the NHS implement the guideline include practical approaches, such as interactive treatment graphs that can be used by healthcare professionals caring for jaundiced babies. There is widespread variation in the treatment of neonatal jaundice and these graphs will help ensure that all babies with jaundice get the right treatment. The graphs are available on the NICE website at: www.nice.org.uk/CG98. An information leaflet for parents and carers, and costing templates and audit tools for managers and commissioners are also available online.


Further information

The guideline and implementation tools are available at: www.nice.org.uk/CG98