For women, trans men and non-binary people in labour, identify and assess any risk factors for early-onset neonatal infection (see box 1 on risks factors for early-onset neonatal infection). Throughout labour, monitor for any new risk factors. [2021]
For guidance on managing prelabour rupture of membranes at term, see NICE's guideline on intrapartum care. [2021]
Red flag risk factor:
suspected or confirmed infection in another baby in the case of a multiple pregnancy
Other risk factors:
invasive group B streptococcal infection in a previous baby or maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
pre-term birth following spontaneous labour before 37 weeks' gestation
confirmed rupture of membranes for more than 18 hours before a pre-term birth
confirmed rupture of membranes for more than 24 hours before a term birth [2026]
suspected or confirmed maternal sepsis in the intrapartum or early postpartum period [2021, amended 2026]
suspected or confirmed chorioamnionitis [2021, amended 2026]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on identification and assessment of risk factors for early-onset neonatal infection before birth.
Full details of the evidence and the committee's discussion are in evidence review D: maternal and neonatal risk factors for early-onset neonatal infection.
If there are any risk factors for early-onset neonatal infection (see box 1 on risk-factors for early-onset neonatal infection), or if there are clinical indicators of possible early-onset neonatal infection (see box 2 on clinical indicators of possible early-onset neonatal infection):
perform an immediate clinical assessment
review the maternal and neonatal history
carry out a physical examination of the baby, including an assessment of vital signs. [2021]
If group B streptococcus infection is identified in the woman, trans man or non-binary person within 72 hours after the baby's birth:
ask those directly involved in the baby's care (for example, a parent, carer, or healthcare professional) whether they have any concerns in relation to the clinical indicators listed in box 2 and
identify any other risk factors present and
look for clinical indicators of infection.
Use this assessment to decide on clinical management (see recommendation 1.10.3 for the framework for making antibiotic decisions). [2021]
Red flag clinical indicators:
apnoea (temporary stopping of breathing)
seizures
need for cardiopulmonary resuscitation
need for mechanical ventilation
signs of shock
Other clinical indicators:
altered behaviour or responsiveness
altered muscle tone (for example, floppiness)
feeding difficulties (for example, feed refusal)
feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension
abnormal heart rate (bradycardia or tachycardia)
signs of respiratory distress (including grunting, recession, tachypnoea)
hypoxia (for example, central cyanosis or reduced oxygen saturation level)
persistent pulmonary hypertension of newborns
jaundice within 24 hours of birth
signs of neonatal encephalopathy
temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental factors
unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation
altered glucose homeostasis (hypoglycaemia or hyperglycaemia)
metabolic acidosis (base deficit of 10 mmol/litre or greater)
Use the following framework, based on the risk factors in box 1 and the clinical indicators in box 2, to make antibiotic management decisions as directed:
In babies with any red flag, or with 2 or more 'non-red-flag' risk factors or clinical indicators:
follow the recommendations in the section on investigations before starting antibiotics and
start antibiotic treatment according to the recommendations in this guideline and
do not wait for the test results before starting antibiotics
in babies without red flags and only 1 risk factor or 1 clinical indicator, use clinical judgement to decide:
whether it is safe to withhold antibiotics and
whether the baby's vital signs and clinical condition need to be monitored. If monitoring is needed, continue for at least 12 hours using a newborn early warning system
for babies without risk factors or clinical indicators of possible infection, continue routine postnatal care as covered in NICE's guideline on postnatal care. [2021]
The Kaiser Permanente neonatal sepsis calculator can be used as an alternative to the framework outlined in recommendation 1.10.3 for babies born after 34+0 weeks of pregnancy who are being cared for in a neonatal unit, transitional care or postnatal ward. It should only be used if it is part of a prospective audit, which should record:
total number of babies assessed using the calculator
number of babies correctly identified by the calculator who develop a culture-confirmed neonatal infection
number of babies incorrectly identified by the calculator who do not develop a culture-confirmed neonatal infection
number of babies missed by the calculator who develop a culture-confirmed neonatal infection. [2021]
If using the Kaiser Permanente neonatal sepsis calculator to assess the risk of early-onset neonatal infection, use the classification given by the calculator to direct management decisions. [2021]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing and managing the risk of early-onset neonatal infection after birth.
Full details of the evidence and the committee's discussion are in evidence review D: maternal and neonatal risk factors for early-onset neonatal infection and evidence review D2: timing of prelabour rupture of membranes to birth and risk of early-onset neonatal infection.
In babies being monitored for possible early-onset neonatal infection:
Consider starting antibiotic treatment (see the section on investigations before starting antibiotics for next steps).
If no further concerns arise during observation reassure the family and, if the baby is to be discharged, give information and advice to the parents and carers (see the sections on information and support for parents and carers before transferring babies home and post discharge planning for babies who have not been given antibiotics). [2021]
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on babies being monitored for possible early-onset neonatal infection.
Full details of the evidence and the committee's discussion are in evidence review D: maternal and neonatal risk factors for early-onset neonatal infection.