SOP for Implementation of Neonatal Early Warning Track & Trigger (NEWTT2) in RAH

Background

Historically, maternity units in GG&C have used the Neonatal Early Warning Score (NEWS) to identify the deteriorating baby. In response to recent SAER recommendations, it was felt that a revised early warning score was necessary for use in the postnatal setting in the Royal Alexandra Hospital to incorporate parental concerns. The NEWTT2 system was produced by the British Association of Perinatal Medicine (BAPM) and published in January 2023 and includes parental concerns as part of its scoring system

Every newborn infant should be provided with the environment and healthcare professional support required to enable the transition of their physiology following delivery, the establishment of infant feeding, and the early development of the family. Additionally, they should be protected to prevent avoidable morbidity and mortality during this phase of adaptation. While the majority of newborn infants require only short-term surveillance there are groups at risk of developing complications particular to the perinatal period. By planning and preparing for these at risk newborn infants we aspire to prevent morbidity that could have life-long consequences for their health and wellbeing. There is no clear evidence of the effectiveness of any specific system or set of observations in the newborn. The National Reporting and Learning System (NRLS) does however identify delays in response to deteriorating observations as contributory to the morbidity of hospitalised patients. This framework is designed for use in postnatal care settings including the delivery suite, postnatal ward and transitional care unit. In the rare event that a baby is deteriorating or at risk of deterioration in a community setting (home or midwifery-led unit (MLU)) the NEWTT2 chart can be used to support monitoring of the baby while transfer to the consultant unit is undertaken without delay. The NEWTT2 working group advise immediate contact with the neonatal team and urgent transfer into the consultant unit from community settings for infants with any observations outside the acceptable normal range. NEWTT2 is not designed to be used for patients being cared for on a paediatric ward.

Implementation Group

Name	Role
Dr Andrew MacLaren (chair)	Consultant Neonatologist - RHC Glasgow, RAH Paisley & ScotSTAR Neonatal Transport Team
Dr Hilary Conetta	Consultant Neonatologist – RHC Glasgow, RAH Paisley
Lisa Milner-Smith	Practice Development Midwife – RAH Paisley
Claire Rowan	Practice Development Midwife – RAH Paisley
Gillian Jamieson	Clinical Risk Midwife – RAH Midwife
Denise McColl	Designated Senior Charge Midwife – RAH Paisley
Laura Flynn	Lead Midwife – RAH Paisley
Mary Ross-Davie	Director of Midwifery – NHS GG&C
Ashley McNamee	ANNP, RHC Glasgow & RAH Paisley
Katrina Armstrong	ANNP, RHC Glasgow & RAH Paisley
Dr Mairi Wilson	Clinical Fellow, RAH Paisley

Babies Eligible for NEWTT2

The number of babies requiring to start NEWTT2 observations is higher than the current number of babies who require NEWS observations. This is in line with BAPM recommendations.

The babies requiring NEWTT2 observations can be summarised as follows:

Table 1: babies requiring to start NEWTT2 observations.

At Risk Group	Specifics
Babies at Risk of Early Onset Sepsis	Babies with risk factors for early onset infection as per the West of Scotland Neonatal Guideline for Early Onset Sepsis.
Babies on the Hypoglycaemia protocol	Babies currently being managed under the West of Scotland Neonatal Guideline for Hypoglycaemia in Term Infants.
Babies born through significant meconium	Babies born with documented evidence of thick meconium at delivery. Insignificant meconium is not an inclusion criteria for NEWTT2.
Babies born before arrival of healthcare professionals (BBA)	All babies with an unplanned delivery outside of hospital. Babies with a planned delivery at home do not require NEWTT2.
Jaundice <24 hours	All babies with evidence of visible jaundice at less than 24 hours of age. Jaundice should be checked by a blood test. Transcutaneous bilirubin monitors should not be used in the first 24 hours.
Babies with signs of respiratory distress	All babies with signs of respiratory distress (grunting, nasal flaring, subcostal or intercostal recession). N.B. the majority of these babies with significant symptoms will require admission to the neonatal unit.
Feeding concerns	Babies who have poor feeding outwith what would normally be expected in a newborn baby. N.B. any bilious vomiting should prompt immediate review.
Neurological concerns	Babies with abnormal tone, abnormal reflexes and abnormal behaviours. N.B. these babies will likely require admission to the neonatal unit.
Babies with evidence of perinatal compromise	Babies with 1 or more cord gases with a pH of <7.0 N.B. these babies should have a repeat blood gas within 4 hours to ensure things are improving.
Babies being scored for withdrawal from maternal drugs.	Babies at risk of symptomatic neonatal abstinence syndrome (see West of Scotland Neonatal Guidance on Neonatal Abstinence Syndrome)
Babies born after mum receives opiates in labour	Babies born by vaginal delivery to mums who have received opiates in the 6 hours prior to delivery.

How Often and For How Long?

As a routine, we would recommend 4 hourly observations in the babies. It is important the first set of observations are completed within 1 hour of requesting that baby should start ‘NEWTT2 obs’. In the majority of cases, the observations can stop after 24 hours if there have been no concerns with baby.

For babies on NEWTT2 observations for meconium, we suggest that these are done hourly for the first 2 hours, then 2 hourly thereafter. Observations can cease at 12 hours if baby remains well.

For babies on NEWTT2 observations for risk of withdrawal due to maternal medications or drugs, we suggest continuing these for 48 hours as there can be a risk of later withdrawal from some medications.

This is summarised in the table below:

Table 2: Intervals Between and Duration of NEWTT2 Observations.

Risk Factor	How Often	Duration
Babies at Risk of Early Onset Sepsis	4 hourly (1^st observations within the 1^st hour of life).	24 hours
Babies on the Hypoglycaemia protocol	4 hourly	24 hours
Babies born through significant meconium	Hourly for the 1^st 2 hours then 2 hourly thereafter	12 hours
Babies before arrival of healthcare professionals (BBA)	4 hourly	24 hours
Jaundice <24 hours	4 hourly	24 hours
Babies with signs of respiratory distress	4 hourly	24 hours
Feeding concerns	4 hourly	24 hours
Neurological concerns	4 hourly	24 hours
Babies with evidence of perinatal compromise	4 hourly	24 hours
Babies being scored for withdrawal from maternal drugs.	4 hourly	48 hours
Babies born after mum receives opiates in labour	4 hourly	24 hours

How to Score:

All babies, on the NEWTT2 chart should have the following recorded at every check:

Temperature
Heart Rate
Respiratory Rate
Colour - pink (normal) OR blue/pale (abnormal)
Feeding status – normal/ reluctant/ poor
Neurological behaviour
Parental concerns – high concern/ some concern, no concern

Only babies at risk of hypoglycaemia require blood sugars checked and documented.

Only babies with signs of respiratory distress require oxygen saturations checked and documented. These should be done post-ductally (left hand, right or left foot).

N.B. All babies will have oxygen saturations checked as part of their routine newborn check. These can also be documented.

Documentation

All observations should be recorded on the NEWTT2 Observation Chart (see below).

Observations in the yellow or blue areas of the chart, generate a score of 1. Observations in the pink area of the chart generate a score of 2. The score should be totalled and acted upon as outlined below. Any observations in the purple area of the chart indicate an unwell child and should generate an immediate review by the neonatal team.

Charts should be kept in the white Maternity Record. Post-discharge, these should be scanned onto Clinical Portal.

All reviews of babies should be documented under ‘Specialist Review’ on Maternity Badger (as is currently done).

Figure 1: The NEWTT2 Chart

Escalation

For babies scored using the NEWTT2 chart, results should be interpreted as per Table 3.

If it is not possible for the ‘primary escalation’ team to review the baby within the requested time frame, it should be escalated to the ‘secondary escalation’ team.

If neither team is able to attend (or cannot be contacted), the neonatal consultant on-call should be contacted.

For any babies with ‘abnormal’ NEWTT2 observations, the midwife in charge of the shift should be made aware.

Remember: when making referrals, the SBAR method should be used.

Table 3: Escalation Policy for NEWTT2

Score	Primary Escalation	Secondary Escalation (if primary escalation not available or not responding to call)
1	Repeat observations in 1 hour If score remains 1 in 1 hour, then escalate as per score of 2-3
2-3	Request review from neonatal FY2 or ANNP within 1 hour.	Neonatal middle-grade on call.
4-5	Request review from neonatal FY2 or ANNP within 15 minutes	Neonatal middle-grade on call
>6	Request immediate review from neonatal FY2 or ANNP. Alert neonatal middle-grade on call.	Neonatal Consultant
Any purple observation	Request immediate review from neonatal FY2 or ANNP. Alert Neonatal Consultant Alert neonatal middle-grade on call.	Consider 2222 call if felt to be necessary.

Appendix: Newborn Early Warning Track and Trigger - NEWTT2

Newborn Early Warning Track and Trigger - NEWTT2 (pdf)

Last reviewed: 29/07/2025

Next review date: 31/07/2028

Author(s): Dr Andrew MacLaren, Consultant Neonatologist .

Approved By: NEWTT2 Implementation Group

References

British Association of Perinatal Medicine. Deterioration of the Newborn (NEWTT2) – A Framework for Practice. January 2023.