Midwives performing the Newborn Infant Physical ...... · Midwives performing the Newborn Infant Physical Examination 1. Introduction and who the guideline applies to: This guideline

Page 1 of 13 Written: May 2008

Last Review: October 2018 Next Review: October 2021

Midwives performing the Newborn Infant Physical Examination V3 Author: Amended by A Dziemianko, Helen Ulyett, Louise Robinson , Deepa Panjwani Contact: L Matthews, Clinical Risk and Quality Standards Midwife Approved by: Maternity Service Governance Group Guideline Register No: C51/2018 (Previously C98/2008)

NB: Paper copies of guidelines may not be the most recent version. The definitive version is in the Policy and Guidelines Library

Midwives performing the Newborn Infant Physical Examination

1. Introduction and who the guideline applies to:

This guideline applies to midwives undertaking the newborn infant physical examination (NIPE) as part of their extended role following completion of a recognised examination of the newborn course. It also applies to those midwives and student midwives who are undergoing training to perform the NIPE. This group must be supervised by a paediatrician or NIPE qualified midwife as per their competency package.

Related Documents:

Joint breastfeeding policy for all Leicestershire NHS Trusts (Hospital and community) Child welfare and child protection concerns protocol Access via InSite child protection page or via www.lscb-llr.org.uk Guideline to support successful breastfeeding of Healthy term babies

Prevention and management of hypoglycaemia on postnatal wards Thermal protection of the newborn Consent to examination or treatment Hand hygiene Patient case note documentation policy Maternity Records Pulse Oximetry screening for the newborn infant UHL guideline

Fetal surveillance – small for gestational age UHL guideline





2. Guidance:

Definition of the newborn infant physical examination:

The newborn physical examination is a holistic assessment of the health and well being of the newborn baby. The baby is examined from top to toe by a qualified healthcare professional, including a screening examination of the heart, hips, eyes and testes in boys. Prevalence of the problems with these four elements is rare but, if left undetected, can, in some cases, result in very detrimental outcomes. There are effective treatments for most of the conditions likely to be found but early diagnosis is essential. (PHE April 2018) The examination is part of an on-going programme of child health surveillance and in addition it provides advice, information and reassurance to parents (Townsend et al 2005).

Aims for midwives undertaking the examination:

• To enable the midwife to provide continuity of care for mothers and babies(DOH 2005, Townsend et al 2005, Better births, 2016)

• To improve the quality of service offered, and extend choice regarding place ofbirth for low risk women (Wolke et al 2002, Townsend et al 2005, Better births,2016)

• Tailor the service for mothers and their families, by facilitating early transferhome of mother and baby (DOH 2005)

• Provide an opportunity for health promotion

• To convey information about what parents can look out for and how they canaccess help, advice and support

• To promote parent baby attachment

• Cost efficiency

Competence:

A midwife undertaking the newborn infant physical examination must:

• Be a registered midwife, who has undergone a recognised examination of thenewborn course and has successfully acquired the skills required.

• Once trained and deemed competent, midwives undertaking the neonatalexamination are accountable for their professional practice and must workwithin their professional guidelines. (NMC 2015)

• All midwives performing the NIPE should complete the NSC NIPE e-learningpackage annually - http://www.e-lfh.org.uk/programmes/

• Skills should be practiced and maintained with an appropriate number ofexaminations performed to retain them. (NSC June 2011). Midwives should beresponsible for maintaining a record of continuing professional development todemonstrate their continuing competence as part of their Revalidation (NMC2018)





Location:

A suitable and safe environment to perform the NIPE.This is at the discretion of the midwife undertaking the examination. The location should offer some privacy and confidentiality. Access to I.T will be required so that the examination can be documented on the NIPE smart system.

If referring a baby to the Midwife led NIPE clinic and the hospital notes will not be available to the Midwife performing the examination, please complete the referral letter in appendix 1 and give it to the mother to take along with the red book to the clinic.

Timing:

The timing of the examination should reflect the physiological adaptations the neonate makes to extra uterine life. The exact timing will in part be determined by the time of birth and the parent’s wishes regarding discharge home if in hospital. The midwife should use professional discretion when determining the exact timing of the examination which should occur within 72 hours following the birth (PHE April 2018). There is no lower limit for when the NIPE can be performed.

If an appropriately trained Health professional is not available for the examination or an early discharge home occurs, the midwife must ensure that there is a plan to access and complete the NIPE check.

Babies suitable for examination by a midwife:

• Birth weight on or above the 10th centile as per the GROW programme

• >37 weeks gestation

• Any baby born where there are no apparent birth injuries or where immediateresuscitation was not required with the exception of inflation breaths.

• The midwife may examine any baby deemed suitable, after it has beenexamined by a Paediatrician and discharged to low risk care.

The following Babies should be reviewed by a Paediatrician and assessed as suitable for a NIPE examination by a midwife:

• Abnormalities detected in the antenatal period

• Any congenital abnormality

• Insulin dependent or gestational diabetes

• Severe haematological disorders ie Haemophilia Known substance misuse –requiring a Paediatric alert form

• Known maternal infection e.g. herpes, HIV

• Admission to Neonatal unit

• Previous neonatal death





Prior to the examination:

• Ensure parents have been offered the UK National Screening committee’sleaflet ‘Tests for you and your Baby’

• Obtain maternal consent for examination of her baby and document her choicein the baby’s postnatal records. Review maternal history regarding past medicalhistory, pregnancy, labour and birth.

• Review outcomes of antenatal screening

• Check for administration of vitamin K to ascertain if it has been given and if anyfurther doses are required

• Check pulse oximetry results

• Obtain family history and particularly sibling history

• Explain limitations of the examination as a screening test

• Discuss with parents how they perceive the baby is progressing e.g. feeding,urination, passing of meconium, and any concerns.

The examination:

The NIPE check should be performed in the presence of the birth mother or the person given designated parental responsibility.

The examination is completed with regard to thermal protection of the baby and cross infection (see related guidelines).

An examination of the 4 main screening elements (NIPE standards, NSC 2018) undertaken:

• Eyes: General examination and elicit the red reflex

• Cardiovascular system including heart sounds and femoral, brachial pulses andcapillary refill time.

• Musculoskeletal system: Hips including Ortolani’s and Barlow’s test, limbs anddigits

• Genitalia: In male infants check the position of the urethra and note whether thetestes are descended. Ensure the infant has passed urine (and the nature ofthe stream in a boy).

In addition to this a systematic examination of the following is also undertaken:

• Observe the baby for posture, movement, tone, colour, cry, and obviousdeviations from the norm, such as dysmorphic features

• Respiratory system - Rate and noise, symmetry of movement, use ofdiaphragm and abdominal muscles

• Head: Head circumference, anterior fontanelle, sutures, structural anomalies,mouth to exclude cleft lip and palate, symmetry and position of ears, nose andneck

• Clavicles to exclude fracture

• Abdominal examination: Palpate for masses/organomegaly, condition of theumbilical cord

• Anus: Check for patency and the passage of meconium

• Spine: Check for bony structures and integrity of the skin





• Neurological system: posture, tone and reflexes

• Skin: Check for colour, texture, lesions, birth marks and rashes. Documentthese on a body map in the hospital records and Child Health Record

Midwives should be alert to the risk factors and signs of child abuse and follow UHL Safeguarding Children guideline (2012) if suspected.

Documentation:

Record all findings in the NIPE smart system and print a copy for the Child Health Record booklet and retain a copy for the maternal records and document in postnatal notes. Record any deviations from normal, subsequent actions taken and discussions with parents. Midwives undertaking training to perform the newborn physical examination must have their findings countersigned by the person supervising their examinations. See Appendix 5 for the Standard Operating Procedure (SOP) for monitoring of the NIPE Smart at UHL by the failsafe team.

Communication:

• Communicate findings to Parents including any potential problems identifiedand recommended action.

• Explain problems such as jaundice that may not be observable in the newbornbut could be significant a few days later.

• Advise on health education as appropriate e.g. infant feeding, baby care,baby’s social capabilities and reducing the risk of sudden infant deathsyndrome.

• Advise on continuing programme of child surveillance including newborn bloodspot screening test, hearing screen, 6-8 week postnatal check.

• Ensure findings are communicated to those providing future health care to thefamily i.e. Midwives, GP, Health Visitor

Midwife referral where a deviation from normal is found in a low risk setting:

The midwife must refer all babies where a deviation from the normal is noted during the examination.

Telephone advice is available to midwives via the Consultant Neonatologist at the Leicester Royal Infirmary

Timeliness of referral should be observed. As a general rule the following should be applied (PHE 2018):

• Eye problems. Review by a Paediatrician within 24 hours (contact NNU if babyis an outpatient) for onward referral to a specialist within 2 weeks, if a cataractor retinoblastoma is suspected (referral letter example appendix 2 can beprinted from NIPE smart system)





• Heart problems- arrange review by a Senior Neonatologist including oxygensaturations and ECG with NNU. (If referral to cardiology is required, useexample letter in appendix 3, printed from NIPE smart system)

• Hip problems:o suspected Dislocatable hips should be seen, scanned and reviewed by a

specialist within 2 weeks of age Email the baby’s details [email protected]/uk and follow the “Orthopaedic referral form”pathway in appendix 3 which can be printed from the NIPE smartsystem).

o Babies with risk factors should be referred for an outpatient hip scanusing a radiology or ICE request form within 6 weeks, refer to theOrthopaedic referral form in appendix 4 for guidance.

o Babies with “clicky” hips should be referred for an outpatient hip scanusing a radiology or ICE request form within 6 weeks, refer to theOrthopaedic referral form in appendix 4 for guidance. DO NOT recordclicky hips as an abnormality on SMART this should be logged as “other”in the outcome and then select requires referral.

o Bilateral undescended testes –refer to neonatologist within 24 hours,unilateral review in 6 - 8 weeks by GP

3. Supporting References:

1. PHE April 2018 NIPE - programme handbook.2. Department of Health (2005) National Service Framework for Children, young

people and maternity services. Standard 11:Maternity service 10.23. National Institute for Clinical Excellence (2006) guideline 37 Routine postnatal

care of women and their babies. NICE. London4. Nursing and Midwifery Council (2018). The Code. Professional Standards of

Practice and Behaviour for Nurses, Midwives and nursing associates.https://nmc.org.uk/standards/code

5. Better births – Maternity services review 20166. NMC Revalidation http://revalidation.nmc.org.uk7. Townsend et al (2004) Routine examination of the newborn: The EMREN

study. An evaluation of an extension of the midwife’s role including arandomized controlled trial of appropriately trained midwives and paediatricSHOs. Health Technology Assessment vol 18 no 14

8. UK National Screening Committee Screening tests for you and your baby.NSC, London https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief

9. Wolke D, Dave S, Hayes J et al (2002) Routine examination of the newbornand maternal satisfaction: A randomised controlled trial. Archives of Diseasesin childhood, fetal and neonatal edition.

4. Audit:

A record of all examinations must be kept on the NIPE smart system for the purposes of clinical audit and KPI reporting.





Appendix 1 – Referral to midwife led NIPE clinic.

Please see further referral sheet on next page.









Appendix 2: Example Eye referral letter printable from the NIPE smart system.





Appendix 3: Example Heart referral letter printable from the NIPE smart system.





Appendix 4: Example Hips referral letter printable from the NIPE smart system.





Appendix 5: Standard operating procedure for monitoring of NIPE Smart at UHL by the

failsafe team.

The NIPE Smart system is provided by Northgate and its use is mandatory for all Maternity

Units nationally. The web-based IT system links the generation of a baby’s NHS number at

birth to a completed NIPE check and audits whether this was performed within 72 hours of

birth.

Babies that are over 48 hours old are alerted as amber on the system and red if the NIPE

check is not completed and the baby is over 72 hours old.

All babies highlighted should be checked on the HISS system to see if they are inpatient and

to avoid contacting families of deceased babies. All newborn morbidities are reported to the

screening team and will be dealt with immediately to avoid outstanding examinations being

chased on a deceased baby but double checking on HISS is still required due to the sensitive

nature of these situations.

GP facility:

Due to the historical funding for the NIPE check there is still not the capacity for all babies to

have their check at UHL and so the responsibility for this is handed over to the GP. Babies

that have gone home and not had their NIPE check are moved into the GP facility within the

UHL site on Smart.

To do this perform a search of “newborn screening not started” and then check each baby

against the HISS system for their episodes. If the baby has gone home view the baby’s

record and click “move” at the bottom of the baby summary page and select GP facility.

Transfer in/out:

Babies who have transferred out of UHL need to be transferred to the care of the hospital that

the baby is inpatient.

These functions can only be performed by super users in the “site facility”.

Search for baby’s record in Smart by NHS number, go to the baby summary page and select

transfer out at the bottom of the page. Select the relevant site, document the reason for

transfer and click “transfer to selected site”.

Babies who transfer in to UHL hospitals need to be transferred into the UHL facility that the

baby is inpatient.

These functions can only be performed by superusers in the “site facility”.

Select admin and transfer in and the check HISS for the location of the baby within UHL. Tick

the right hand box to accept the baby and select the correct facility for the baby.

Occasionally babies will be transferred into UHL from Nottingham but the baby has gone

home so these need accepting into our site by ticking the right hand box and select GP facility.

You can use the case notes in Smart to help with locating these babies.





Merging records.

Search on missing NHS number in each individual facility for LRI & LGH. Match all babies on

this list with the record in the system that contains the NHS number.

Outcome data.

Periodically the outcomes for Hips, hearts, eyes and undescended testes should be

completed within the NIPE smart system. This is particularly important for Hips as this is

monitored quarterly through the KPI’s and in the future will not be amendable locally.

DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT

Author / Lead Officer:

A Dziemianko Job Title: Midwifery Team Lead

Reviewed by: A Dziemianko and H Ulyett

Approved by: Maternity Service Governance Group Date Approved: 10.06.14 and 20.07.16 19.12.18

REVIEW RECORD

Date Issue Number

Reviewed By Description Of Changes (If Any)

27.03.14 V2 As above General update. Insertion of targets for referral

July 2016 V3 A Dziemianko, H Ulyett, F Ford, JBehrsin and J Cusack

Updated in general. Clearer guidance re training and referral pathways

October 2018 V4 L.Robinson, A.Dziemianko, H.Ulyett, D.Panjwani M.McLean

Changes to include student midwives, less specific wording around which babies can be checked by midwives, no lower limit for performing the NIPE check and updating of referral pathways

DISTRIBUTION RECORD:

Date Name Dept Received

13.06.14 All Midwives who perform Neonatal Examination

Maternity

July 2016 All Midwives who perform Neonatal Examination

Maternity

December 2018

All Midwives and student midwives who perform Neonatal Examination

Maternity