Download Trust Guideline on Routine Oxygen Saturation Measurement on the

Trust Guideline on Routine Oxygen Saturation Measurement on the New-born
(Pulse Oximetry)
In:
Maternity services, Delivery Suite, NICU, Postnatal ward
By:
Midwives and Maternity Care Assistants, NICU medical and
nursing staff
For:
New-born babies
Key words:
Pulse Oximetry, Oxygen saturation, Congenital Heart Disease
Written by:
Dr Rahul Roy (Consultant Neonatologist)
Supported by:
Head of Midwifery: Mrs Glynis Moore
Clinical Director: Dr David Booth
Assessed and
approved by the:
Clinical Guidelines Assessment Panel 17 September 2014
Reported as approved
Clinical Standards Group
Effectiveness Sub-Board
Document issued:
September 2014
To be reviewed before:
September 2017
To be reviewed by:
Dr Rahul Roy
Document supersedes: None
Document Reg. No:
CA5175
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.
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 1 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the
Newborn (Pulse Oximetry)
Quick reference guideline/s
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 2 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the Newborn (Pulse Oximetry)
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 fetal 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.
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 3 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the Newborn (Pulse Oximetry)
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
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 4 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the Newborn (Pulse Oximetry)
postductal (feet) oxygen saturations should be checked by the neonatal team. 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
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 5 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the Newborn (Pulse Oximetry)
4. All babies with a positive pulse oximetry test will be audited by using a standardized
regional proforma
Summary of development and
registration and dissemination
consultation
process
undertaken
before
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.
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 6 of 7
Trust Guideline on Routine Oxygen Saturation Measurement on the Newborn (Pulse Oximetry)
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
4)
Fig 2
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
Fig 5: Good trace with low saturation
saturation
p
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
Author/s:
Dr R Roy
Valid until: September 2017
Document: Routine Oxygen Saturation Measurement on the Newborn
Copy of complete document available from Trust Intranet
Date of issue: September 2014
Document Ref No: CA5175
Page 7 of 7