Newborn Identification and Labelling Clinical Guideline - V2.0 July 2020
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Newborn Identification and Labelling
Clinical Guideline
V2.0
July 20201. Aim/Purpose of this Guideline
1.1. This guideline is for all birth unit and obstetric unit staff to use in the
identification and labelling of all new born babies.
1.2. This version supersedes any previous versions of this document.
Data Protection Act 2018 (General Data Protection Regulation – GDPR)
Legislation
The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to
process personal and sensitive data. The legal basis for processing must be identified
and documented before the processing begins. In many cases we may need consent;
this must be explicit, informed and documented. We cannot rely on opt out, it must be
opt in.
DPA18 is applicable to all staff; this includes those working as contractors and providers
of services.
For more information about your obligations under the DPA18 please see the
Information Use Framework Policy or contact the Information Governance Team
rch-tr.infogov@nhs.net
1.3. This guideline makes recommendations for women and people who are
pregnant. For simplicity of language the guideline uses the term women
throughout, but this should be taken to also include people who do not
identify as women but who are pregnant, in labour and in the postnatal
period. When discussing with a person who does not identify as a woman
please ask them their preferred pronouns and then ensure this is clearly
documented in their notes to inform all health care professionals (NEW
2020).
2. The Guidance
2.1. At the Birth
When delivery is anticipated the midwife will prepare two infant identity
bands using black indelible ink, writing the mother’s surname, hospital
number, clearly. Check these details are correct with the mother and/or
partner against her own printed patient identity band.
If there has been a change of shift, the new midwife must write out new
labels.
After delivery the midwife must write date and time of birth and place both
bands (one on each of the infant’s ankles) before leaving the room, double
checking with the parents that the details are correct.
NB: The bands need to be tight enough not to slip off but not so tight as to
cause tissue damage or compromise circulation.
Newborn Identification and Labelling Clinical Guideline V2.0
Page 2 of 82.2. On transfer to the Postnatal Ward
The baby requires handwritten labels initially. Following generation of the
NHS number an identity band, printed from the maternity computerised
system, must be placed on one ankle. This must be a printed barcoded
label (NEW 2020).
The postnatal ward staff member, delivery suite staff member and mother
will check together the infant’s identity bands with the mother’s identity
band, cross referencing the ID label on the mother’s medical notes. This
check will be documented in the mother’s postnatal notes by both staff
members (NEW 2020).
2.3. On Transfer to the Neonatal Unit
The delivery suite midwife will check both hand written infant’s identity
bands (NEW 2020) with the ANNP, Paediatrician or Neonatal Nurse who
are receiving/taking the baby, cross checking the details with the mothers
identity label if the mother is present or the mothers ID label in her medical
notes.
The Delivery Suite Coordinator must delegate the generation of a hospital
number as soon as possible for the baby requiring admission to the
neonatal unit as a matter of urgency in order to facilitate safe labelling of
samples and the provision of safer emergency treatment for the baby on the
neonatal unit.
2.4. Lost, detached or damaged identity bands
If one identity band is lost, detached or damaged another identity band
should be printed out; it should be checked by the health care professional
with the woman then immediately reapplied to the baby’s ankle. This should
be documented in the midwifery documentation.
If all three (NEW 2020) identity bands are missing, inform the lead
midwife/shift coordinator, check that all the other baby’s on the ward or unit
are correctly labelled and that the woman/ health professional whose baby
is not labelled is confident that it is her/correct baby. Print out 3 (NEW
2020) new labels and check label details with mother and second health
professional before applying to the baby.
If more than one baby is found with all (New 2020) labels missing or if any
woman questions the identification of her baby, inform the lead midwife/shift
coordinator who will inform the Matron or Head of Midwifery within normal
working hours and the site coordinator outside normal working hours, who
will decide whether the incident needs to be escalated immediately to the on
call Trust executive.
A Datix form must be completed and a full serious untoward investigation
carried out. Consideration will be given to DNA testing where the identity is
in question.
2.5. Readmission of baby
It is the admitting midwife/nurses’ responsibility to print out 3 (New 2020)
baby identification labels. All (New 2020) labels should be checked by the
midwife/nurse with the woman before securing them to the baby’s ankles.
Newborn Identification and Labelling Clinical Guideline V2.0
Page 3 of 8This should be documented in the midwifery documentation.
If the parents are not present the labels should be checked by the health
care professional and a second health professional against the baby’s
hospital details before applying to the baby’s ankle.
Daily label checks continue whilst the baby remains an inpatient.
2.6. Deceased babies
For deceased babies please refer to the current Pregnancy Loss and Early
Neonatal Death – Clinical Guideline RCHT 2013 baby as different labels are
used.
3. Monitoring compliance and effectiveness
Element to be Record keeping by obstetricians and midwives
monitored
Lead Postnatal ward manager
Tool 1. Was the baby correctly labeled at delivery?
2. Is it documented that the baby’s labels were checked at
handover between health professionals in different clinical
settings?
3. Did the baby have 3 labels on with a minimum of 1 being a
barcoded label
4. On the postnatal ward did the identity labels have the baby’s
name, baby’s Cr number, baby’s NHS number, DOB, time of
birth and mother’s full name?
Frequency Once in the lifetime of the guideline or earlier if identified through
risk management
Reporting A formal report of the results will be received annually at the
arrangements Maternity Forum or Clinical Audit Forum. Maternity Risk
Management Newsletter
Acting on Any deficiencies identified on the annual report will be discussed at
recommendations the Maternity Forum and Clinical Audit Forum and an action plan
and Lead(s) developed.
Action leads will be identified and a time frame for the action to be
completed by.
The action plan will be monitored by Maternity Risk Management
until all actions complete.
Change in Required changes to practice will be identified and actioned within
practice and a time frame agreed on the action plan.
lessons to be A lead member of the forum will be identified to take each change
shared forward where appropriate.
The results of the audits will be distributed to all staff through the
risk management newsletter/audit forum as per the action plan.
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Inclusion & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Newborn Identification and Labelling Clinical Guideline V2.0
Page 4 of 8Appendix 1. Governance Information
Newborn Identification and Labelling Clinical
Document Title
Guideline V2.0
This document replaces (exact Newborn Identification & Labelling - Clinical
title of previous version): Guideline V1.3
Date Issued/Approved: 2nd July 2020
Date Valid From: July 2020
Date Valid To: July 2023
Directorate / Department
Sarah Coe, Postnatal Ward Manager
responsible (author/owner):
Contact details: 01872 252159
This guideline is for all birth unit and obstetric unit
Brief summary of contents staff to use in the identification and labeling of all
new born babies.
Identification, newborn, security, labelling, baby
Suggested Keywords:
labels, label, neonate, baby
RCHT CFT KCCG
Target Audience
Executive Director responsible
Medical Director
for Policy:
Approval route for consultation Maternity Guideline Group
and ratification: Care Group Meeting
General Manager confirming
Debra Shields
approval processes
Name of Governance Lead
confirming approval by specialty
Caroline Amukusana
and care group management
meetings
Links to key external standards None required
Related Documents: None
Training Need Identified? None
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet Intranet Only
and Ratification):
Document Library Folder/Sub
Midwifery and Obstetrics
Folder
Newborn Identification and Labelling Clinical Guideline V2.0
Page 5 of 8Version Control Table
Version Changes Made by
Date Summary of Changes
No (Name and Job Title)
Sally Budgen
April 2006 1.0 Initial document
Delivery Suite Lead
Jan Clarkson
January Reviewed and updated in line with trust
1.1 Maternity Risk
2010 documents
Manager
Reviewed and updated in line with electronic Jo Crocker and Pat
st
1 August patient identification, including advice on Nicols
1.2 missing label, babies being readmitted and
2013 Delivery Suite and
deceased babies. Neonatal Unit Lead
Mairead Archard.
2nd March
1.3 Minor amendments only Post Natal Ward
2017
Manager
GDPR updated template
1.3. Inclusion statement
2.2. Documenting of barcode label check
2.3. Checking identity bands on transfer to S Coe
2nd July
V 2.0 NNU Postnatal Ward
2020
2.4 and 2.5 Addition of 3 labels not 2 Manager
throughout
Appendix 1 updated governance template
Appendix 2 updated EIA template
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
express permission of the author or their Line Manager.
Newborn Identification and Labelling Clinical Guideline V2.0
Page 6 of 8Appendix 2. Equality Impact Assessment
Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Newborn Identification and Labelling Clinical Guideline V2.0
Directorate and service area: Is this a new or existing Policy?
Obs and Gynae Directorate Existing
Name of individual/group completing EIA Contact details:
Sarah Coe 01872-252159
1. Policy Aim
Who is the
strategy / policy / This guideline is for all birth unit and obstetric unit staff to
proposal / service use in the identification of all new born babies.
function aimed at?
2. Policy Objectives
Safety of newborn babies.
3. Policy Intended
Outcomes
To ensure all babies are identifiable whist under Trust care.
4. How will
you measure
Compliance Monitoring Tool.
the outcome?
5. Who is intended
to benefit from the All women and their newborn babies.
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
x
b). Please list any Please record specific names of groups:
groups who have Maternity Guidelines Group
been consulted Care Group Directive
about this procedure.
c). What was the
outcome of the
consultation? Guideline approved
Newborn Identification and Labelling Clinical Guideline V2.0
Page 7 of 87. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age
x All women and newborn babies
Sex (male, female
non-binary, asexual x All women and newborn babies
etc.)
Gender
reassignment x All women and newborn babies
Race/ethnic
communities x All women and newborn babies
/groups
Disability
(learning disability,
physical disability,
sensory impairment,
x All women and newborn babies
mental health
problems and some
long term health
conditions)
Religion/
other beliefs x All women and newborn babies
Marriage and civil
partnership x All women and newborn babies
Pregnancy and
maternity x All women and newborn babies
Sexual orientation
(bisexual, gay, x All women and newborn babies
heterosexual, lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust rationale
in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.
Name of person confirming result of initial
Sarah Coe
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead debby.lewis@nhs.net
Newborn Identification and Labelling Clinical Guideline V2.0
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