Aims To audit the documentation of risk factors for neonatal sepsis and whether guidelines for prophylactic antibiotic use are being followed. Additionally, to audit whether babies are receiving the routine cares that are advised for all neonates, including Vitamin K, Tetracycline eye ointment (TEO) and cord care with chlorhexidine.

Methods A retrospective case notes audit of 40 maternal records.

Results We found that documentation of risk factors was generally poor. 35% had duration of rupture of membranes recorded, and where prolonged rupture of membranes was noted, prophylactic antibiotics were not given. There was no documentation of maternal temperatures. Two cases were suggestive of chorioamnionitis and no action was taken. Three mothers were treated with IV antibiotics post C-Section but it was unclear whether there were concerns regarding sepsis or if this was routine practice. Two babies were noted to have fevers postnatally. One was treated appropriately and the other did not receive any treatment.

In terms of routine cares for neonates, 13% had documentation of vitamin K being administered, 88% had TEO, and 90% were advised on cord care. All mothers had HIV status documented, but for the one HIV positive mother in the sample, there was no record of whether her baby received appropriate treatment.

Conclusion Overall, documentation of risk factors was poor and where risk factors or symptoms suggestive of sepsis were noted, they were not always acted on appropriately. Documentation of routine cares was variable, with good use of TEO and cord care, but low numbers for vitamin K.

Following teaching and implementation of new documentation forms, we are currently re-auditing practice.